Lippincott for Taylor: Fundamentals of Nursing Chapter 16- Outcome Identification & Planning

Nurses may generate the patient outcome by asking themselves:

"What patient changes or outcomes will result in the prevention or resolution of this problem?"

Deriving Outcomes form Nursing Diagnoses

- Outcomes are derived form the PROBLEM STATEMENT of the nursing diagnosis - For each nursing diagnosis in the plan of care, AT LEAST ONE outcome should be written that, if achieved, demonstrates a direct resolution of the problem statement - Other outcomes that contribute to the resolution of the problem may be written

What are competencies of the registered nurse withing the planning stage?

-Develops an individualized, holistic, evidence-based plan in partnership with the health care consumer and interprofessional team. -Establishes the plan priorities with the health care consumer and interprofessional team. -Advocates for responsible and appropriate use of interventions to minimize unwarranted or unwanted treatment and/or health care consumer suffering. -Prioritizes elements of the plan based on the assessment of the health care consumer's level of risk and safety needs. -Includes evidence-based strategies within the plan to address each of the identified diagnoses, problem, or issues -Incorporates an implementation pathway that describes steps and milestones. -Identifies cost and economic implications of the plan. -Develops a plan that reflects compliance with current statutes, rules and regulations, and standards. -Modifies the plan according to the ongoing assessment of the health care consumer's response and other outcome indicators. -Documents the plan in a manner that uses standardized language or recognized terminology.

Why is it important for the nurse to work in partnership with the patient and family during outcome identification and planning?

-Establish priorities -Identify and write expected patient outcomes -Select evidence-based nursing interventions -Communicate the nursing care plan

A formal care plan allows nurses to:

-Individualize care that maximizes outcome achievement -Set priorities -Facilitate communication among nursing personnel and their colleagues -Promote continuity of high-quality, cost-effective care -Coordinate care -Evaluate the patient's responses to nursing care -Create a record that can be used for evaluation, research, reimbursement, and legal purposes -Promote the nurse's professional development

What three basic stages of planning are critical to comprehensive nursing care?

-Initial -Ongoing -Discharge

Three helpful guides to facilitate clinical reasoning when prioritizing patient problems are:

-Maslow's hierarchy of human needs -Patient preference -Anticipation of future problems

Nurses should consider which realistic factors when determining patient-centered outcomes?

-Patient's health state and overall prognosis -Expected length of stay -Growth and development Patient values and cultural considerations -Other planned therapies for the patient -Available human, material, and financial resources -Risks, benefits, and current scientific evidence -Changes in status that indicate the need to modify usual expected outcomes

To be measurable, outcomes should have the following:

-Subject: the patient or some part of the patient -Verb: the action the patient will perform -Conditions: the particular circumstances in or by which the outcome is to be achieved (not every outcome specifies conditions) -Performance criteria: expected patient behavior or other manifestation described in observable, measurable terms -Target time: when the patient is expected to be able to achieve the outcome

Why are nursing interventions performed?

1) Monitor patient health status and response to treatment 2) Reduce risks 3) Resolve, prevent, or manage a problem 4) Promote independence with activities of daily living 5) Promote optimum sense of physical, psychological, and spiritual well-being 6) Give patients the information they need to make informed decisions and be independent

What is the order of Maslow's hierarchy of needs, ranging from most to least important?

1) Physiologic needs (MOST important) 2) Safety needs 3) Love and belonging needs 4) Self-esteem needs 5) Self-actualization needs (least important)

What 6 aims should be met by healthcare systems in regard to the quality of care?

1) Safe: avoiding injury 2) Effective: avoiding overuse and underuse 3) Patient centered: responding to patient preferences, needs, and values 4) Timely: reducing waits and delays 5) Efficient: avoiding waste 6) Equitable: providing care that does not vary in quality to all recipients

Alfaro-LeFevre suggests that nurses ask themselves what questions when establishing priorities?

1) What problems need immediate attention & what could happen if I wait to attend to them? 2) Which problems are my responsibilities & which do I need to refer to someone else? 3) Which problems can be dealt with using standard practices? 4) Which problems aren't covered by protocols or standard plans but must be addressed to ensure a safe hospital stay & timely discharge?

What 6 factors should be considered when chop a nursing intervention?

1) desired patient outcomes, (2) characteristics of the nursing diagnosis, (3) research base for the intervention, (4) feasibility for doing the intervention, (5) acceptability to the patient, and (6) capability of the nurse.

When determining patient-centered outcomes, nurses should ask patients to describe how many major goals?

2 to 3

What is an algorithm?

A set of steps that approximates the decision process of an expert clinician and is used to make a decision; these clinical rules are typically embedded in a branching flow chart

A nurse caring for a client admitted with deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using? A standardized care plan Guidelines An algorithm An order set

A standardized care plan Standardized care plans are prepared plans of care that identify nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. An algorithm in nursing is a set of developed evidence-based clinical practice guidelines that guides nursing interventions. A guideline is a statement by which to determine a course of action. An order set is a predetermined set of orders by a prescriber that dictates care of the client.

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care? Tell another nurse about this client statement. Document that the depression has resolved. Encourage the client to join a therapy group. Add the nursing diagnosis: Risk for Self-Harm.

Add the nursing diagnosis: Risk for Self-Harm. Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates risk for self-harm, not resolution of the depression. The nurse will perform additional assessment and add the new nursing diagnosis to the care plan. Changing the care plan to incorporate this new data makes it the most effective for treating the client. Telling another nurse could assist in treatment, but is less formal and less effective, because the entire team needs access to this information. While group therapy may provide help, it does not address the client's current mental health status related to self-harm.

The nurse is caring for a client who has had abdominal surgery. Which intervention(s) will the nurse include to prevent complications for this client? Select all that apply. Turn the client and change position frequently. Assist the client with the use of incentive spirometry. Encourage the client to lie in supine position only. Administer analgesic medication as required. Ensure the client remains in bed.

Assist the client with the use of incentive spirometry. Turn the client and change position frequently. Administer analgesic medication as required. Various interventions are needed to prevent postoperative complications. After abdominal surgery, some primary concerns are pain management, prevention of thromboembolism, prevention on pneumonia and constipation. The nurse will plan for interventions that will prevent these potential primary complications from happening. Mobility is critical to the prevention of pneumonia, thromboembolism and constipation. The client should not be encouraged to remain in bed at all times or to lay in the supine position, because these two actions are risk factors for the named complications.

The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the priority? Client will discuss drinking habits in therapy sessions the day after admission. By day 2 of admission, the client will remain safe and without injury from withdrawal symptoms Within 3 days, client will be discharged. Client will commit to completing a 12-step program within 24 hours of admission.

By day 2 of admission, the client will remain safe and without injury from withdrawal symptoms Safety is a top client priority. About half of all clients with alcohol addiction may develop alcohol withdrawal, which can lead to delirium tremens (DTs) with an estimated 15% fatality rate. The client who can recognize the need for tranquilizers can be treated to avoid DTs. It is unrealistic to expect the client to begin a 12-step program only 48 hours after being admitted in withdrawal. Similarly, starting therapy the day after admission would be premature. There is no way of knowing if a 3-day admission is sufficient for the client's needs.

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours? Client reports no headache. Client is drowsy after lunch. Client is normotensive. Client lipids are within range.

Client is normotensive. A specific, expected client outcome is written for each day in a collaborative plan of care. An expected client outcome after 24 hours of treatment for hypertension is to have the blood pressure return to the expected range of between 90/60 and 120/80 mm Hg. The other options do not directly indicate successful control of hypertension.

For possible nursing diagnoses, interventions seek to:

Collect additional data to rule out or confirm the diagnosis

Patients who are learning to live with a chronic illness may need _______________ instead of teaching.

Counseling

What should each nursing intervention include?

Date Verb: Action to be performed Subject: Who is to do it Descriptive phrase: How, when, where, how often, how long, or how much Signature

Which guideline should the nurse follow when including interventions in a plan of care? Make sure the nursing interventions are unrelated to the original outcomes. Date the nursing interventions when written and when the plan of care is reviewed. Make sure the attending health care provider approves of and signs the nursing interventions. Make sure each nursing intervention does not describe the action the nurse should perform.

Date the nursing interventions when written and when the plan of care is reviewed. Nursing interventions describe, and thus communicate to the entire nursing staff and health care team, the specific nursing care to be implemented for the client. Interventions should contain the date, a verb (action to be performed), the subject (who is to do it), and a descriptive phrase (how, when, where, how often, how long, or how much). The interventions should be dated both when written and when the care plan is reviewed. The interventions should directly relate to the outcomes. The health care provider does not approve and sign the interventions, because they are nursing interventions.

What are Low-priority diagnoses?

Diagnoses that aren't specifically related to the current level of health or well-being

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? Surveillance Supervisory Educational Maintenance

Educational Demonstrating, teaching, and observing a return demonstration are classified as educational interventions. The remaining terms refer to aspects of monitoring the client and do not apply to this scenario.

A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse? Promote oral fluid intake between meals. Reassess in 4 hours and document the findings. Encourage hourly use of the incentive spirometer. Provide oral pain medication before ambulation.

Encourage hourly use of the incentive spirometer. Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates possible postoperative atelectasis. Changing the care plan to promote lung expansion is the most direct and effective method to resolve this problem. Reassessment is needed, but this does not replace the need for interventions.

What are the competencies of the registered nurse within the outcome identification stage?

Engages the health care consumer, interprofessional team, and others in partnerships to identify expected outcomes. -Formulates culturally sensitive expected outcomes derived from assessments. -Uses clinical expertise and current evidence-based practice to identify health risks, benefits, costs, and/or expected trajectory of the condition. -Collaborates with the health care consumer to define expected outcomes integrating the health care consumer's culture, values, and ethical considerations. -Generates a time frame for the attainment of expected outcomes. -Develops expected outcomes that facilitate coordination of care. -Modifies expected outcomes based on the evaluation of the status of the health care consumer and situation. -Documents expected outcomes as measurable goals. -Evaluates the actual outcomes in relation to expected outcomes, safety, and quality standards.

What do well-written outcomes define?

Evaluative strategies to be used by the nurse

What are common errors made when writing patient outcomes?

Expressing the patient outcome as a nursing intervention Using verbs that are not observable and measurable Including more than one patient behavior/manifestation in short-term outcomes Writing outcomes that are so vague that other nurses are unsure of the goal of nursing care

When planning nursing care for each day, the following must be considered:

Have changes in the patient's health status influenced the priority of nursing diagnoses? For example, when a routine home visit to an older adult reveals evidence of possible elder abuse, a new diagnosis may result in a new set of care priorities. Have changes in the way the patient is responding to health and illness or the care plan affected those nursing diagnoses that can be realistically addressed? For example, a nurse might have identified Ineffective Coping as a high-priority diagnosis for the patient after the patient learned the medical diagnosis and planned to initiate counseling. If the patient adamantly requests to be left alone for a day to think things through, however, the nurse has to modify priorities of care for that day. Are there relationships among diagnoses that require that one be worked on before another can be resolved? Can several patient problems be dealt with together?

Which diagnoses pose the greatest threat to the patient's health & well-being?

High-priority diagnoses

What is the link between identifying a patient's strength or problem & providing an appropriate nursing response?

Informal planning in practice

Quality-of-life outcomes describe:

Key factors that affect someone's ability to enjoy life & achieve personal goals

_________________ outcomes also may be used as discharge goals, in which case they are more broadly written and communicate to the entire nursing team the desired end results of nursing care for a particular patient.

Long-term

Generally speaking, why does it make sense to deal with medical problems (or suspected medical problems) first?

Many human response problems are gone if medical problems are resolved

For collaborative problems, interventions seek to:

Monitor for changes in status Manage changes in status with nurse- and physician-prescribed interventions Evaluate response

What is true of nursing responsibilities with regard to a health care provider-initiated intervention (health care provider's order)? Nurses do carry out interventions in response to a health care provider's order. Nurses do not carry out health care provider-initiated interventions. Nurses are not legally responsible for these interventions. Nurses are responsible for reminding health care providers to implement orders.

Nurses do carry out interventions in response to a health care provider's order. A health care provider-initiated intervention is initiated in response to a medical diagnosis, but carried out by a nurse in response to a doctor's order. Both the health care provider and the nurse are legally responsible for these interventions. Although nurses are not responsible for reminding health care providers to implement orders, nurses may request a health care provider to implement an order or question an existing order by the health care provider if the nurse believes it is in the client's best interests.

Which elements are common to any type of plan of care? Select all that apply. Nursing diagnosis Client goals Nursing interventions Past medical history Medical diagnosis

Nursing diagnosis Client goals Nursing interventions

Assigning a low priority to a diagnosis that the patient wants to ignore, but can result in harmful consequences might be considered

Nursing negligence

At least _____________ outcome(s) per nursing diagnosis must directly resolve the problem statement in the nursing diagnosis

One

__________________ planning is carried out by any nurse who interacts with a patient

Ongoing

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning? Outcome Discharge Ongoing Initial

Ongoing Ongoing planning is carried out by any nurse who interacts with the client following admission and before discharge, and the chief purpose is to keep the plan up-to-date. Initial planning is developed by the nurse who performs the admission nursing history and the physical assessment. Discharge planning prepares the client for discharge from the health care setting. Outcome planning is not a specific type of nursing planning, although it would most likely be performed as part of initial planning.

A nurse assesses the vital signs of a client who is one day postoperative following a colostomy. The nurse then uses the data to update the client plan of care. What are these actions considered? Initial planning Discharge planning Ongoing planning Comprehensive planning

Ongoing planning Ongoing planning is carried out by any nurse who interacts with the client. Its chief purpose is to keep the plan up-to-date to facilitate the resolution of health problems, manage risk factors, and promote function. The nurse caring for the client uses new data as they are collected and analyzed to make the plan more specific and accurate and, therefore, more effective. -Comprehensive planning involves establishing a plan of care that addresses all aspects of the client's care needs and updating that plan of care as needed until the client is discharged. Comprehensive planning has three phases: Initial planning, ongoing planning, and discharge planning. -Initial planning is performed by the nurse with the admission nursing history and the physical assessment and results in the development of a comprehensive plan of care that addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate client goals and the related nursing care. In acute care settings, discharge planning begins when the client is admitted for treatment—or even before admission. It ensures that the nurse uses teaching and counseling skills effectively to help the client and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors at home competently.

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining? Process Structure Cost-effectiveness Outcome

Outcome An outcome evaluation determines the extent to which a client's behavioral response to a nursing intervention reflects the expected client outcome. A broad view of evaluation in health care includes three approaches, directed toward structure, process, and outcome, depending on the focus of evaluation and the criteria or standards being used. Process/implementation evaluation determines whether program activities have been implemented as intended. Cost-effectiveness evaluation compares the relative costs to the outcomes (effects) of two or more courses of action. Structure evaluation assesses the effectiveness of various health care structures.

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client? The nurse will help the client ambulate the length of the hallway once a day. Offer to help the client walk the length of the hallway each day. The client will become mobile within a 24-hour period. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. Goals must be client-centered, specific, measurable, attainable, realistic, and timebound. "Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse" has all of these characteristics. "The nurse will help the client ambulate the length of the hallway once a day" is not specific in whether assistance is required, is not timebound, and is not client-centered, in that the nurse is the subject of the sentence, not the client. "Offer to help the client walk the length of the hallway each day" is a nursing intervention, not a client outcome. "The client will become mobile within a 24-hour period" is not specific or measurable.

Under no circumstances should a nurse implement a questionable intervention, even at the urging of a _______________ or other professional.

Physician

What are standardized care plans?

Preprinted, established guidelines used to care for patients who have similar health problems

What is the primary goal of nursing care plans?

Primarily, nursing care plans ensure that the nursing team works efficiently to deliver holistic, goal-oriented, person-centered care to patients

What are the three steps of the Omaha system?

Problem, intervention, and outcome

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? Maintenance Psychomotor Psychosocial Surveillance

Psychomotor Psychomotor interventions include activities such as positioning, inserting, and applying. A psychosocial intervention focuses on supporting, exploring, and encouraging. Maintenance and surveillance are monitoring interventions.

What is the major focus of interventions for actual nursing diagnosis?

Reduce or eliminate contributing factors of the diagnosis Promote higher-level wellness Monitor and evaluate status

For risk nursing diagnoses, interventions seek to:

Reduce or eliminate risk factors Prevent the problem Monitor and evaluate status

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." Which nursing action is the priority?

Resolve the client's anxiety

What does SMART stand for?

Specific, Measurable, Attainable, Realistic, Timely

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs? Present the client with videos and books about diet changes that reduce inflammation. Ask the client's learning style, then teach diet information using that style. Start from client's knowledge, teach about diet modifications, and check for learning. Answer the client's questions about diet alterations, and then evaluate understanding.

Start from client's knowledge, teach about diet modifications, and check for learning. The nursing interventions written to assist a client to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what assessments need to be made and what nursing interventions, including teaching, counseling, and advocacy, need to be done. They should also include evaluation of the outcome of the intervention. "Start from client's knowledge, teach about diet modifications, and check for learning" provides the most comprehensive intervention for this client, as it includes assessment of the client's current level of knowledge, teaching, and evaluation of the teaching. None of the other answer options includes all three of these elements.

Which outcome for a client with a new colostomy is written correctly? The client will know how to care for the stoma by 3/29/20. The client will demonstrate proper care of the stoma by 3/29/20. The client will be able to care for stoma and cope with psychological loss by 3/29/20. Explain to the client the proper care of the stoma by 3/29/20.

The client will demonstrate proper care of the stoma by 3/29/20. Expected client outcomes must be client-centered, specific, measurable, attainable, realistic, and time-bound. "The client will demonstrate proper care of the stoma by 3/29/20" has all of these characteristics. "Explain to the client the proper care of the stoma by 3/29/20" is a nursing intervention, not an outcome. "The client will know how to care for the stoma by 3/29/20" is not measurable. The client demonstrating a technique is measurable. "The client will be able to care for stoma and cope with psychological loss by 3/29/20" contains two goals in one statement.

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome? The nurse has omitted the time frame. The outcome should indicate what the nurse will do. The nurse has omitted the defining characteristics. The nurse has not made any error in writing the outcome.

The nurse has omitted the time frame. Outcomes are client-centered, use action verbs, identify measurable performance criteria, and include a time frame as to when the outcome should be achieved. The time frame has been omitted. Defining characteristics are a component of the nursing diagnosis, not a client outcome. Because outcomes are client-centered, they describe what the client will do, not what the nurse will do.

Why are many sets of nursing interventions inadequate?

They fail to indicate the ongoing assessment priority needs for a specific problem or goal.

What is the primary purpose of the outcome identification and planning step of the nursing process?

To design a plan of care with and for the patient; Once implemented, results in the prevention, reduction, or resolution of patient health problems AND the attainment of the patient's health expectations

What is the chief purpose of ongoing planning?

To keep the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function

What is the Omaha system?

a research-based, comprehensive practice and documentation standardized taxonomy designed to describe client care.

What are affective outcomes?

describes changes in patient values, beliefs, and attitudes

What are cognitive outcomes?

describes increases in patient knowledge or intellectual behaviors

What are psychomotor outcomes?

describes patient's achievement of new skills

Clinical outcomes describe:

expected status of health issues at certain points in time after treatment is complete

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: identifies the unhealthy response preventing desired change. identifies client strengths. identifies factors causing undesirable response and preventing desired change. suggests client goals to promote desired change.

identifies factors causing undesirable response and preventing desired change. The cause of the client health problem is referred to as the etiology. The problem statement of the nursing diagnosis suggests the client goals, and the cause of the problem (etiology) suggests the nursing interventions. Identifying the unhealthy response preventing desired change would occur during the evaluation phase of the nursing process. Client strengths are identified during the nursing diagnosis phase.

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing: goal. intervention. diagnosis. evaluation.

intervention. A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance client goals and outcomes. Nursing diagnoses are statements of the client's actual or potential health problems that the nurse is seeking to address through interventions and are the overarching driver of goal-setting, care planning, and interventions. Evaluation, the final phase of the nursing process, involves assessing the client's response to interventions on an ongoing basis and making any necessary adjustments and changes to the nursing care plan.

Diagnoses that are not life-threatening are ranked as _____________ priorities

medium

What is consultation?

process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution

What is discharge planning?

systematic process of preparing the patient to leave the health care facility and for maintaining continuity of care

Functional outcomes describe:

the person's ability to function in relation to the desired usual activities