Shared Flashcard Set

Details

Nursing process: Planning outcomes
fudnamentals of nursing
40
Nursing
Undergraduate 1
10/14/2009

Additional Nursing Flashcards

 


 

Cards

Term

Chapter 5

Nursing Process

Planning Outcomes

Definition
Term

 

 

Formal Planning

Definition
Is a conscious, deliberate activity involving decision making, critical thinking, and creativity
Term

 

 

Definition
The end product of formal planning is a holisitc plan of care that adresses the pt's unique problems and strengths
Term

 

 

Informal Planning

Definition
Making mental notes or plans to notify the physician and obtain an order for an increase in the analgesic dose
Term

 

 

Initial Planning

 

Definition

* Begins with first pt. contact.

* Written as soon as possible after the intial assessment.

*Develop a preliminary plan with whatever infromation you have.

Term

 

 

 

Definition

All nursing process steps are over lapping and interdependent.

develop a plan of care with realsitic goals and effective nursing orders. You must have accurate, complete assessment data and corretly idnetified and prioritized nursing diagnosis.

Term

 

 

Definition

The goals then suggest nursing inteventions.

*Which are written as nursing orders in the planning interventions phase.

* Plan of care is carried out in the implementation pahse.

* The evaluation step of the goals.desired outcomes serve as criteria for evaluating whether the nursing care has been effective.

Term

 

 

Discharge Planning

Definition
The process of planning for self care and continuity of care after the patient leaves a health care setting.
Term

 

Discharge Planning begins at assessment

Definition

* Physical condition and functional and self-care limitation.

*Emotional stability and ability to learn.

* Financial resources.

*Family or other caregiver available.

*Environment, both home and and community.

Term

 

 

Ongoing Planning

Definition
Change made in the plan as you evaulaute the pt's responses top care or as you obtain new data and make new nursing diagnosis.
Term

 

 

Written Discharge Plans

Definition
All pt's need at least some discharge planning, but you will bot always need a seperate, written discharge plan.
Term

 

Discharge Planning Requires Collaboration

Definition
Comprehensive discharge planning involves significant collaboration. Pt involvement is improtant for acheiving desired outcomes.
Term

 

 

Comprehensive Nursing Care Plan

 

 

(also called patient care plans)

Definition

*A document; the control source of information needed to guide holistic goal-oriented care to address each pt's unique needs.

*Specifies dependent,interdependent, and independent nursing fucntions necessary for care of a specific pt. and usually uses both standardized and individual appraoches to care.


Term

 

Why is a written Nursing Care Plan Important?

Definition
  • Ensuring that care is complete.
  • Providing continuity of care.
  • Promoting efficient use of nursing efforts.
  • Providing a guide for assessment and charting.
  • Meeting the requirement of accrediting agency.
Term

 

Comprehensive Care Plan continues

4 different

Kinds of Care

Definition
  • Basic needs and ADL's.
  • Medical diagnosis and collaborative. problems.
  • Special Discharge needs/teaching needs.
Term

 

Preprinted Standardized

Plans

Definition
  • A comprehensive care paln usually includes one or more preprinted, standardized documents.
  • Standardized plans save nurisng time, promotes cosnsitency of care and help ensure that nurses do not overlook improtant interventions.
Term

 

 

Protocols

(Specific therapeutic action usually required for a clinical problem unique to a subgroup of pts's)

Definition
May be written for a particular medical diagnosis, treatments or diagnostic tests.
Term

 

 

Unit Standards of Care

Definition

The care that nurses are expected to provide for all pt's in defined situations.

Describe the minimum level of care the nurses are expected to acheive given the instuition resources and the cleint population.

Term

 

 

Standardized Nursing Care Plans

(Model)

Definition
Guides that detail the nursing care that is usually needed for a particular nursing diagnosis or for all nursing diagnosis that commonly occur with a medical condition.
Term

 

 

Critical Pathways

Definition
  • Used in managed care systems.
  • Are outcome-based,interdisciplinary plans that seq. pt. care according to case types.
  • Specify predicted patient outcomes and broad intervention for each day, or in some situations, for each hour.


Term

 

 

Special Discharge Teaching Plans

Definition
May use standardized plan for discahrge planning and teching or include as teaching in a nursing diagnosis care plan.
Term

 

Process for Writing Individual Nursing Care Plan

Definition
  • Make a working problem list.
  • Decide which problem can me managed with standardized care plans/critical pathways.
  • Individualized the standardized plan as needed.
  • Transcribe medical orders o apporiate documents.
  • Write ADL's and basic care needs in special sections of the kardex care plan or computer.
  • Develop individual care plans for problems not addressed by stand documents.
Term

 

Process for Writing Individualized Nursing Care Plan

 

2nd part(cont'd)

 

 

Definition
Term

 

 

Planning Cleint Goals/Outcomes

Definition

Goals (expected outcomes,desired out comes, or predicted outcomes). Describe the chges in pt. helath status you hope to acheive.

Nursing Sensitive Outcomes: Those that can be influenced by nursing interventions

Term

 

 

Log Term Goals

Definition

 

To be acheived over a longer period of time (week, month, more)

Term

 

 

Short Term Goals

Definition

 

To be acheived within a few hours or days.

eg. Free of pain within hours painfree from the rest of hospital stay,

Term

 

What are the Components of A Goal Statement

Definition
  • Subject: Always the Patient.
  • action: What you want patient to do.
  • Performance criteria: How, waht, where criteria.
  • Target time: Performance behaviour should be acheived.
  • Special Conditions:
Term

 

Essential

vs.

Non-Essential Goals

Definition
  • Essential/patient goals- Flow from the problem side of the nursing disgnsosi because the problem side describes the unhealthy response that you intend to change.
  • Non-essential goal derive from the etiology.

The Rule

For every nursing diagnosis, you must state one goal that, if acheived, would demosntrate resolution or improvement of the problems

Term

 

 

Goals for Actual, Risk, and Possible Nursing Diagnosis

Definition
You will develop expected outcomes to promote, maintain, or restore health, depending on the status of the nursing diagnosis
Term

 

How do Goals Relate To Nursing Diagnosis

Definition
  • Exptected outcomes are dreived directly form the nursing diagnosis.
  • The problem statmeent of a nursing diagnosis describes the response or health status that you wish to change.
  • A desired outcome states the opposite if the problme and implies that this repsosne is what the interventions are intended to acheive.
Term

 

Goal for

Collborative

Problems

 

 

Definition
  • Primary intervention are medical and, if there is obstruction, probably surgical.
  • All goals on a nursing care plan should be nursing-sensitive goals.
  • Collbaorative goals are appropriate on multidisciplinary care plans and critical pathways.
Term

 

 

How do I use standardized

Terminolgy for Outcomes

Definition
The ANA has also approved several standardized vocabularies for describing client outcomes.
Term

 

How do I write Goals for Wellness Diagnosis

Definition
Expected outcomes for wellness diagnoses describe behaviours or responses that demonstrate health maintenance or acheivement of an even higher level of health
Term

 

 

Outcomes for Special Teaching Plans

Definition

Teaching objectives

Describe what the patient is to learn and the observable behaviours that will demonstrate learning, and they should state whether learning is to be cognitive, psychomtor, or affective.


 

Term

 

 

Reflecting Critically about Expected outcomes/Goals

Definition

For each nursing diagnosis:

  1. Is there at least one goal that, when met, would demonstrate problem resolution; that is does at least one goal flow from the problem cause.
  2. Are the predicted outcomes adequate to completely address the nursing disgnsosis.
Term

 

Reflecting Critically about Expected outcomes/Goals

 

(cont'd)

Definition

For each expected outcome:

  1. Is the outcome appropriate for the nursing disgnosis.
  2. Is each outcome derived from only one nursing diagnosis.
  3. Does each outcome describe only one pt. response or behaviour.
Term

 

Reflecting Critically about Expected outcomes/Goals

 

(cont'd)

Definition

For each expected outcome:

  1. Is the outcome stated as a patient behaviour, not a nurse activity.
  2. Is the outcome stated in positive terms?
  3. Is the outcome measurable or observable?
Term

 

Reflecting Critically about Expected outcomes/Goals

 

(cont'd)

Definition

For each expected outcomes:

  1. Are the performance criteria specific abd concrete.
  2. Does each goal include all the necessary parts?
  3. Is the expected outcome realsitic and acheivable by this patient: given the avaialble resources
Term

 

Reflecting Critically about Expected outcomes/Goals

 

(cont'd)

Definition

For each expected outcomes:

  1. Does the outcome conflict with the medical or other collaborative treatment plan?
  2. Does the pt. family, or community value the outcome?
Term

 

Reflecting Critically about Expected outcomes/Goals

 

(cont'd)

Definition

For each expected outcomes:

  1. Does the patient family, or community value the outcome.
  2. Does the goal conflict with any religious/cultural values?
Supporting users have an ad free experience!