Nurs 1014

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1

outcome identification, planning

______ and _______ steps of the nursing process, the nurse works in partnership with the patient and family to: • Establish priorities • Identify and write expected patient outcomes • Select evidence-based nursing interventions • Communicate the plan of nursing care

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goal

is an aim or an end.

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patient outcome

is an expected conclusion to a patient health problem, or in the event of a wellness diagnosis, an expected conclusion to a patient’s health expectation.

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expected outcomes

is used to refer to the more specific, measurable criteria used to evaluate the extent to which a goal has been met

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Initial planning

is performed by the nurse with the admis- sion nursing history and the physical assessment.

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Standardized care plans

are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem.

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Ongoing planning

is carried out by any nurse who interacts with the patient.

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Discharge planning

is best carried out by the nurse who has worked most closely with the patient and family, possibly in conjunction with a nurse or social worker with a broad knowledge of existing community resources.

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Nursing Outcomes Classification (NOC)

developed by the Iowa Outcomes Project presents the first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing intervention

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nursing intervention

as “any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes”

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nurse-initiated intervention

is an autonomous action based on scientific rationale that a nurse executes to ben- efit the patient in a predictable way related to the nursing diagnosis and projected outcomes.

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Nursing Intervention Classification (NIC)

the first comprehensive, validated list of nursing interventions applicable to all settings that can be used by nurses in multiple specialties, greatly facilitates the work of identifying appropriate interventions.

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physician-initiated interventions

initiated by a physician in response to a medical diagnosis but is carried out by a nurse

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collaborative interventions

Nurses also carry out treatments initiated by other providers such as pharmacists, respiratory therapists, or physician assistants

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Consultation

a process in which two or more people with varying degrees of experience and expertise discuss a problem and its solution, often proves helpful.

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plan of nursing care (patient care plan)

is the written guide that directs the efforts of the nursing team working with patients to meet their health goals.

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computerized plans of nursing care

as part of the electronic medical record.

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Clinical pathways (critical pathways, CareMaps)

are tools used in case management to communicate the standardized, interdisciplinary plan of care for patients.