Chapter 5

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Nursing Process: Planning Outcomes
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1

What is Planning?

Can be formal or informal

2

Formal planning is:

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

3

Informal planning is:

making mental notes or plans

4

Intial planning:

Begins with first client contact; is written as soon as possible after initial assessment

5

Ongoing planning:

causes changes to be made in the plan as you evaluate the client's responses to care

6

Discharge planning:

planning for self-care and continuity of care after client leaves healthcare setting

7

When does discharge planning being?

with initial assessment

8

Discharge planning requires:

collaboration

9

Nursing care plans:

the central source of information needed to guide holistic, goal-oriented care; address each client's unique needs

10

Why is a written nursing care plan important?

Ensures care is complete, provides continuity of care, promotes efficient use of nursing efforts, provides a guide for assessing and charting, and meets requirements of accrediting agencies

11

Unit standards of care:

General guides, describe the care that nurses are expected to provide for all clients in defined situations

12

Standardized nursing care plans

detailed nursing care for a particular nursing diagnosis

13

Critical pathways are:

outcome-based, interdisciplinary plans that sequence client care based on case type

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Integrated plans of care:

standardized plans designed to be both care plan and documentation form

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Individualized Nursing care plan used to address:

nursing diagnoses unique to a particular client

16

Teaching plan/special discharge:

May use standardized plan for discharge planning and teaching or include as teaching in a nursing diagnosis care plan

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Computerized Care plan:

computer generates list of suggested interventions

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How can you individualize computerized care plan?

Type in own interventions as needed

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Process of writing individualized nursing care plan:

Make a working problem list, decide which problems can be managed with standardized care plans or critical pathways, individualize plan as needed, transcribe medical orders to appropriate documents

20

Goals:

Describe the changes in client health status you hope to achieve

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Nursing-sensitive outcomes:

Those that can be influenced by nursing interventions

22

Long-term goals:

To be achieved over a longer period of time

23

Short-term goals:

to be achieved within a few hours or days

24

What are the components of a goal statement?

Subject, action, performance criteria, target time, special conditions

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Nonessential goals:

Derive from the etiology

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Essential goals:

derive from the problem

27

For every nursing diagnosis, you must state:

one goal that, if achieved would demonstrate resolution or improvement of the problem

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Why is a written patient care plan important?

It ensures that care is complete, it provides continuity of care, it promotes efficient use of nursing efforts, it provides a guide for assessments and charting, and meets the requirements of accrediting agencies

29

What information does a comprehensive patient care plan contain?

Basic needs and ADLs, medical/multidisciplinary treatment, nursing diagnoses and collaborative problems, special discharge needs or teaching needs.

30

Protocols:

cover specific actions usually required for a clinical problem unique to a subgroup of patients

31

Unit standards of care:

describe the care that nurses are expected to provide for all patients in defined situations

32

Standardized patient care plans:

detail the nursing care that is usually needed for a particular nursing diagnosis or for all nursing diagnoses that commonly occur with a medical condition

33

Critical pathways are:

often used in managed care systems; they are outcomes-based, interdisciplinary plans that sequence patient care according to case type.

34

Integrated plans of care:

standardized plans that function as both care plan and documentation form

35

Individualized Patient care plans:

address nursing diagnoses unique to a particular client

36

Rationales state:

the scientific principles or research that supports nursing interventions

37

Mind-mapping is a:

technique for showing relationships among ideas and concepts in a graphical, or pictorial way

38

What is the process for wiring an individualized patient care plan:

Make a working problem list, decide which problems can be managed with standardize care plans or critical pathways, individualize the standardized plan as needed, transcribe medical orders to appropriate documents, write ADLs and basic care needs in special sections of the Kardex, care plan or computer screen, develop individualized care plans for problems not addressed by standardized documents.

39

Goals describe:

the changes in patient health status that you hope to achieve

40

Nursing-sensitive outcomes are:

those that can be influenced by nursing interventions

41

Subject is:

Understood to be the client, but it can also be a function or part of the client

42

Action verb:

indicates the action the client will perform: what the client will learn, do or say.

43

Performance criteria:

Describes the extent to which you expect to see the action or behavior

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Target time:

realistic date or time by which the performance/behavior should be achieved

45

Special conditions:

describes the amount of assistance or resources needed or the experiences/treatments the client should have to perform the behavior.

46

Outcome label:

is broadly stated; neutral to allow for positive, negative, or no change in patient health status

47

Indicators:

observable behaviors and states you can use to evaluate patient status

48

Measurement scale:

NOC has a five-point measurement scale for describing patient status for each indicator

49

What does NOC stand for?

Nursing Outcomes Classification

50

What is NOC?

Standardized vocabulary of 385 nursing-sensitive outcomes developed by a research team at the University of Iowa.

51

Community health goals:

those you would use to specify and evaluate the health of groups, aggregates or populations

52

The U.S. Public Health Service has proposed these 4 goals:

1. Attain high-quality, longer lives free of preventable disease, disability, injury and premature death; 2. Achieve health equity, eliminate disparities, and improve the health of all groups. 3. Create social and physical environments that promote good health for all; 4. Promote quality of life, healthy development and healthy behaviors across all life stages

53

NOC currently includes:

16 outcomes targeted to Community Health, which they define as "outcomes that describe the health, well-being, and functioning of a community of population

54

The clinical Care classification was developed by:

Virginia Saa for use in home health nursing

55

In clinical care classification you form goals by:

adding modifiers to the nursing diagnoses

56

Teaching objectives describe:

what the patient is to learn and the observable behaviors that will demonstrate learning; they should state whether learning is to be cognitive, psychomotor or affective

57

For each nursing diagnosis, you can ask yourself:

Is there at least goal one that, when met, would demonstrate problem resolution?

Are the predicted outcomes adequate to completely address the nursing diagnosis?