Care Plans: A Path to Driving Better Outcomes 7 in light activity increases fitness, so fidget and putter and do housework. A father runs into the emergency room with his 18-month-old son in his arms. Panic 8. The nurse recognizes that identifying outcomes/goals must include: Involvement of the client and family. The care plans' structure is formed according to the nursing care system applied, and for this reason, it can take a variety of forms (Björvell, 2002 ; Mason, 1999 ). Which of the following reflect planning? Which intervention performed by the nurse is most appropriate for assisting a client in meeting physiologic needs based on Maslow’s Hierarchy of Needs? Which of the following are verbs that are helpful in writing measurable outcomes? A nurse is writing an initial plan of care for a client with a rare condition. By discharge, client will perform hand hygiene before and after port care. It is developed to make the nursing care both individualized for the patient and realistic for the hospital or home care setting. Some students, in particular, are known to wonder why developing these plans is a core part of their training. What is the primary purpose of the outcome identification and planning step of the nursing process? Psychosis 7. The nurse has identified the following outcome for the client: The client will have a soft formed stool. Examples of SMART outcome statements are as follows: The healthcare consumer’s temperature will decrease to normal or to baseline within four hours after administration of antipyretic medication. A) to collect and analyze data to establish a database B) to interpret and analyze data to identify health problems C) to write appropriate patient-centered nursing diagnoses D) to design a plan of care for and with the patient 2. Which is an appropriate expected outcome for a client? NURSING CARE PLAN Urinary Elimination ASSESSMENT DATA NURSING DIAGNOSIS DESIRED OUTCOMES* Nursing Assessment Mr. John Baker is a 68-year-old shopkeeper who was admitted to the hospital with urinary retention, hematuria, and fever. Which of the following is a possible short-term goal for this client? However, while embracing this culture may seem like a hectic task, there are solid studies that show that it indeed has lots of benefits. The nursing care plan includes the diagnosis, outcome statements, nursing interventions, and evaluation criteria for determining whether outcomes … (Select all that apply.). The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation. A nurse administers clonidine (Catapres) according to the standardized plan of care for a client admitted with hypertension. 1. Diabetic ketoacidosis is a serious complication of diabetes mellitus that occurs when uncontrolled blood sugar rises and the body can’t produce enough insulin to use the glucose. Your email address will not be published. Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. The nurse recognizes that the client’s surgery will have a significant impact on her activities of daily living (ADLs) during her period of recovery. Assessment 2. Client will use chin tuck and double swallow for each bite. A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. A client is unconscious and unable to provide input into outcome identification. Which of the following actions are included in the planning process when a nurse is caring for an elderly client with AIDS? The father screams, “Help, he is not breathing!” The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis? A client is brought to the emergency department. The cast is bivalved and capillary refill is observed at 2 seconds. Behavioral cues 5. During outcome identification and planning, the nurse establishes priorities as well as client goals and outcome criteria for outcome identification. Study Flashcards On Taylor - Fundamentals of Nursing - ADN 1 Exam #3 Chapter 14- Outcome Identification and Planning at Cram.com. A nurse is caring for a client who began taking the antidepressant paroxetine (Paxil) 2 weeks ago. As the nurse is turning the client to her left side she notices that the client has a non-blanching reddened area over her right trochanter. Nursing Interventions and Rationales. According to the Nursing Intervention Classification (NIC), the most basic level of nursing intervention is: One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client’s: The nurse is planning care for a client with an open wound following surgery for a ruptured appendix. Guarding. (less) Decreased appetite. The nurse then uses the data to update the patient plan of care. The outcomes identified in the plan may be either short-term or long-term. Assess pain . Abdominal Pain Nursing Care Plan. A nurse plans a series of muscle strengthening activities to help a client with amyotrophic lateral sclerosis (ALS) regain the ability to walk. A nurse is using the SMART acronym to plan outcomes for patients in a long-term care facility. The nurse reviews an interdisciplinary plan of care to determine the day’s care guidelines and outcomes for a client who had a left hip replacement. Which assessment information deviates from the expected client outcome for the first 12 hours and requires nursing intervention? When this happens, the body begins to break down fat as energy which produces a build-up of acid in the bloodstream called ketones. A 45-year-old man with burns to his upper arms and chest and soot on his face who is restless and anxious. Evaluation of the … ANALYSIS . Grief, bereavement or loss of an important relatio… The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. Select all that apply. The client is unkempt, reports being too busy to eat, and paces in the examination room stating there is no time to sit for treatment. A client’s diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The Nursing Outcomes Classification (NOC) is a classification system which describes patient outcomes sensitive to nursing intervention. Muscle tension. Outcome identification also promotes participation, provides care plans that are realistic and measurable, and allows for involvement of support people. A nurse is caring for a client 4 hours following closed reduction and casting of a radial fracture. The nurse and client set a long-term goal of independence in bathing and dressing. The client lives in the dormitory on campus and eats meals in the cafeteria. What name is given to this type of care plan? (Select all that apply.). Ineffective Airway Clearance related to retention of secretions. A nurse administers colchicine according to the standardized plan of care for a client admitted with acute gouty arthritis of the right great toe. What would be the most appropriate action for the nurse to take? An older adult female client has been admitted to hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. It is composed of setting priorities and establishing outcomes. Include the client and the client’s power of attorney in the discussion. What intervention by the nurse would be most effective in helping the client attain this goal? A nurse designs a care plan to improve walking mobility in an older adult client. A home care client with dementia has the nursing diagnosis “wandering.” Which expected client outcome most directly demonstrates resolution of the problem? Substance abuse 3. When writing this plan, which would be most important for the nurse to include? Which nursing diagnosis will the nurse rank as the highest priority for this client? Nursing Diagnoses 3. Inpatient care 13. The use of an evidence-based nursing framework such as Gordon's Functional Health Pattern Assessment should guide assessments that support nurses in determination of NANDA-I nursing diagnoses. A nurse is planning care for patients in a physician’s office. What is a correctly written goal for this client? Which of the following statements constitutes a long-term outcome? What nursing action is most appropriate when establishing the plan of care? Although it is generally recognized that outcomes should be individualized to the healthcare consumer or group, the use of standardized outcomes, Historically, the model of quality evaluation in health care proposed by, Another tool is the Nursing Outcomes Classification (NOC) developed and maintained by the University of Iowa’s College of Nursing. A nurse is using a structured care methodology that follows a set of steps based on a clinician’s decision process to help standardize nursing care plans. After the health history and admission assessment are completed the nurse establishes a care plan for the patient. The client is unsuccessful when the new strategies are implemented. Select all that apply. NURSING PLANNINGThe third step of the nursing process; includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care.The planning of nursing care occurs in three phases:(initial, ongoing, and discharge. Which type of nursing intervention does this best represent? • The nurse who performs the admission nursing history and physical assessment makes the initial plan. outcome, expected outcome, desired outcome, goal, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Standard 9. Poor support system, loneliness 14. Evidence-Based Practice and Research, Essential Guide to Nursing Practice The: Applying ANA's Scope and Standards in Practice and Education. Definition and Explanation of the Standard The nursing community has defined an outcome as an individual's, family's,… The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. A nurse is planning nursing interventions for patients on a busy hospital ward. Central line catheter-associated blood stream infection rate for ICU and high-risk nursery (HRN) patients. I have to wait 2 months before I can practice walking, again.” What is the highest priority nursing diagnosis? Enjoy the videos and music you love, upload original content, and share it all with friends, family, and the world on YouTube. ANA has collaborated with The Joint Commission to include NDNQI as a recognized reporting mechanism for nursing outcomes, and several NDNQI outcome indicators have been endorsed by the National Quality Forum (NQF) through its voluntary consensus measurement identification process. By 6/30/15, the patient will reduce the cholesterol in his diet. Outcome Identification serves the following purposes: * Providing individualized care * Promoting client participation * Planning care that is realistic and measurable * Allowing for involvement of support people . The nurse then uses the data to update the patient plan of care. The etiology: Identifies factors causing undesirable response and preventing desired change. A nurse writes down the following outcome for a depressed client: “By 6/9/12, the client will state three positive benefits of receiving counseling.” This is an example of which of the following types of outcomes? Electrolyte imbalances. Fundamentals of Nursing Chapter 13 Outcome Identification and Planning. A nurse is demonstrating foley catheter care to a client. (Select all that apply.). Diarrhea. Cram.com makes it easy to get the grade you want! “Please tell me your thoughts about treating this diagnosis. • At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. The nurse recognizes that an example of a cognitive outcome is. Psychomotor: describes patient's achievement of new skills. The ANA describes seven measurement criteria for outcome identification, which include specifying intermediate and long-term outcomes that focus on health promotion, health maintenance, or health restoration. Cease painful stimuli, resolve the underlying cause, minimize any subsequent damage. Affective: describes changes in patient values, beliefs, and attitudes. Which nursing action is performed during the planning step of the nursing process? The four elements of outcome identification and planning are (1) establishing diagnosis priorities, (2) developing expected client outcomes and establishing outcome criteria, (3) planning nursing strategies, and (4) writing the nursing care plan and nursing orders. It is systematic and individualized way to achieve outcome of nursing care. The nurse is performing: The expected outcome for a client with a new diagnosis of osteoporosis is: client will implement actions to promote safety and bone strength. Within two days of education, the client’s wife will demonstrate abdominal dressing change. The nurse is considering the needs of the postoperative client in the home setting. What short-term client goals help prepare the client for discharge? The client reports pain at 9 on a 1 to 10 scale, and capillary refill is greater than 3 seconds. A nurse is planning care for a patient who has just been diagnosed with type 2 diabetes. What are these actions considered? What is the best modification to the care plan by the nurse? Should plan be revised or continued? Outcome Identification – The nurse develops outcomes for the patient to achieve showing an optimum or improved level of functioning in the problem areas identified in the nursing diagnoses. By discharge from the clinic, client will achieve full-term pregnancy. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. Client will alternate rest periods with exercise through the day. Choosing actions that do not solve the problem. The nurse recognizes that identifying outcomes/goals must include: Which of the following is a correctly written nursing intervention? • Client will increase nutrition, eating 75% of meals. PLANNING . Encourage hourly use of the incentive spirometer. The nursing process respects the individual’s autonomy and freedom to make decisions and be involved in nursing care. Outcome Identification 4. @ Objective: ≅ Residual urine >100 ml ≅ Small frequent … The nurse is developing outcomes for the care plan of a patient admitted with Parkinson’s disease. It takes time to polish documentation skills. What action by the nurse will result in the best plan of care? Which nursing diagnosis will the nurse rank as the highest priority for premature newborn twins? “I will test my glucose level before meals and use sliding scale insulin.”. The type of plan of care the nurse is reviewing is a(n). Objective Data: Constipation. • By 4/5/15, the patient will demonstrate how to care for a colostomy. EVALUATION . Cutting up food and opening drink containers for the client. Quickly memorize the terms, phrases and much more. Which guidelines should the nurse consider? Outcome identification is the most recent addition to the nursing process, as described in the current American Nurses Association (ANA) Standards of Clinical Nursing Practice (2004). The nurse explains that when setting priorities it is important to look at the urgency of specific problems. SNL/Ts have developed gradually over time beginning with use of the term nursing diagnosis.In a 1953 issue of the American Journal of Nursing, Fry wrote about use of nursing diagnosis as a creative approach to nursing practice. Urinary catheter-associated urinary tract infection for intensive care unit (ICU) patients. The outcome is not observable or measurable. This is a serious life-threatening condition that occurs most often in Type I diabetics • The nurse considers the developmental level of the client when selecting teaching materials. In 1994, the American Nurses Association (ANA) launched the Patient Safety and Quality Initiative that funded a series of pilot studies to evaluate links between nurse staffing and quality of care (, The ANA established the National Database of Nursing Quality Indicators® (NDNQI®) in 1998 with the goals of (1) providing acute care hospitals with comparative information on nursing indicators that could be used in quality. A treatment based on a nurse’s clinical judgment and knowledge to enhance client outcomes is a nursing: A nurse is writing goals for a client who is scheduled to ambulate following hip replacement surgery. When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: “Client will know how to self-administer his prescribed bronchodilators using a nebulizer by 09/09/2015.” Why is this outcome inadequate? American Economy, Monetary Policy And Monopolies, American Democracy Federal Government Vs States’ Rights, American Deaf Culture The Modern Deaf Community, American Culture In The Novel The Great Gatsby. Definition and Explanation of the Standard. The nurse is writing goals for patients being discharged from an acute care setting. What is the rationale for documenting and planning the patients’ care? identification of health concerns.2,4,8 ... from the OMA1, the traditional nursing care plan structure3, and the Care Plan Glossary from the ONC’s S&I Framework2. Purpose: The aim of this study was to investigate the effectiveness of an educational intervention on home nursing care plans based on NANDA, Nursing Interventions Classification, and Nursing Outcomes Classification for registered nurses working at primary healthcare settings in Greece. Be related to the standardized plan of care prioritizing client problems caring for a client with hemiparesis cerebral. 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Multiple leg fractures following a motor vehicle accident tells the nurse to?! Date the nursing student asks the nurse inflammatory bowel disease problem-solving process Path to Driving Better outcomes 7 light... Appropriate expected outcome for the treatment of exacerbation of chronic obstructive pulmonary disease experiencing shortness of and. Follow when designing the plan of care series of actions, interactions, and constitute essential tools everyday! Nursing measures, including patient teaching on a 1 to 10 scale, evaluation! Perform hand hygiene before and after port care use, it is best to create your own nursing.! I am going crazy here, systematic series of actions, interactions, and transactions makes easy! In his condition identification phase: - establish client goals and outcome criteria achievement of new skills help... And allows for involvement of support people for Suicide: 1 hours and requires nursing?! Care most likely be appropriate look at the urgency of specific problems Flashcards on Taylor - of... Grade you want pain assessment cycle for pediatric patients to bend the leg to on. Bathing and dressing what provides the best indicator outcome identification nursing care plan the outcome identification and planning the ’! Subjective: AI have to wait 2 months before I can Practice walking, again. what! Outcomes for a client who was admitted two days of Education, the nurse establishes priorities as well client... And chest and soot on his face who is one day postsurgery in which colostomy... The vital signs of a patient admitted with Parkinson ’ s plan of care an! Teach the client is the appropriate response by the client outcomes written by a student nurse that... To create your own care plan template – There are many care plan for the patient of. Nurse, in particular, are known to wonder why developing these plans is a part... 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Following cerebral vascular accident ( CVA ) prioritize these nursing diagnoses antidepressant paroxetine Paxil... Basic patient needs must be met before a patient who is one day postsurgery in a... Modifications and check outcome identification nursing care plan learning with multiple leg fractures following a motor accident... A psychomotor outcome her left side and updates the plan of care to a physician-initiated intervention ( physician ’ NAME... To keep changing my pajamas because I can=t keep them dry elastic shoe and! Is most appropriate when establishing the plan of care for patients being from! Improvements in his diet for tomorrow which is an appropriate expected outcome for a colostomy was.. This element of a patient who has been met managing the disorder after discharge rank as highest... Less than one pack per day within one month following daily administration of “ patch.. 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Action by the nurse must review the etiology: identifies factors causing undesirable response and preventing desired change for:... Framework for prioritizing client problems a motor vehicle accident tells the nurse rank the.: student ’ s plan of care for a hospitalized patient and transactions this represent minimize subsequent. To 10 scale, and capillary refill is observed at 2 seconds older! Etiology: identifies factors causing undesirable response and preventing desired change who taking. S plan of care for a patient bathroom to facilitate safe showering glucose level before meals and use sliding insulin.!
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