Questions and Answers
What is the purpose of outcome identification and planning?
Design a plan of care for and with the patient that results in prevention, reduction, or resolution of health problems and attainment of health expectations.
What are the benefits of outcome identification and planning?
They are unique to a person.
Identify three elements of comprehensive planning.
Initial planning, ongoing planning, discharge planning.
What are the priority levels for patient health problems?
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How are patient goals and nursing orders derived from nursing diagnosis?
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What is ongoing planning in nursing care?
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What are nurse-initiated interventions?
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What characterizes physician-initiated interventions?
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What are collaborative interventions?
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Describe five common problems related to planning.
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What is NOC (Nursing Outcomes Classification)?
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What does NIC (Nursing Interventions Classification) offer?
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What are long-term goals in patient care?
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What do short-term goals refer to?
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What defines cognitive outcomes?
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What are psychomotor outcomes?
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What are affective outcomes?
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What should be done if a patient does not cooperate with the care plan?
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What are the risks and responsibilities of delegating nursing interventions?
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Describe why reassessment after nursing intervention is important.
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List examples of how nursing interventions and nursing outcomes classifications can be used to implement care.
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What are some variables that influence the implementation of a care plan?
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Study Notes
Purpose of Outcome Identification and Planning
- Design a patient-centered care plan to prevent, reduce, or resolve health problems and meet patient health expectations.
- Achieving this plan relies on clearly defined patient outcomes.
Benefits of Outcome Identification and Planning
- Tailored specifically to individual patient needs.
Elements of Comprehensive Planning
- Initial: Conducted upon patient admission with a physical assessment.
- Ongoing: Continuously updated through interaction with the patient.
- Discharge: Most effectively performed by the nurse who has provided direct care.
Prioritizing Patient Health Problems
- High priority: Problems posing the greatest threat to patient well-being.
- Medium priority: Non-threatening diagnoses.
- Low priority: Diagnoses not directly related to the current health issue.
- Utilize Maslow's hierarchy for effective prioritization.
Goals and Nursing Orders from Nursing Diagnosis
- Each nursing diagnosis should correspond with at least one outcome reflecting resolution of the identified problem.
Developing Nursing Care Plans
- Outcomes can be long-term (over one week) or short-term (accomplished in a specified timeframe).
Evaluating Planning Skills
- Use measurable criteria in patient goals to assess the specified behaviors.
Clinical Reasoning and Prioritization
- Determine which problems need immediate attention versus those that can wait.
- Identify responsibilities: direct nursing tasks or referrals needed.
- Recognize which issues can be addressed using standard care plans and which require individualized attention.
Types of Nursing Interventions
- Nurse-initiated interventions: Actions performed by a nurse without physician orders.
- Physician-initiated interventions: Actions initiated by a physician, executed by nurses under orders.
- Collaborative interventions: Treatments initiated by other healthcare providers carried out by nurses.
Common Planning Problems and Remedies
- Involvement: Ensure active patient participation in the planning process.
- Data Collection: Gather sufficient and accurate data to formulate precise nursing diagnoses.
- Update the Care Plan: Consistently revise the plan as necessary.
Nursing Outcomes Classification (NOC)
- Classifies nursing-sensitive patient outcomes and indicators for effective evaluation in clinical settings.
Nursing Interventions Classification (NIC)
- Provides a comprehensive, validated list of nursing interventions applicable across multiple specialties.
Maslow's Hierarchy of Needs
- Framework for prioritizing patient needs based on levels of importance.
Ongoing Planning Responsibilities
- All nurses interacting with the patient are accountable for keeping the care plan updated and relevant.
Discharge Planning
- Begins at admission, executed by the nurse closely engaged with the patient.
Long-term vs Short-term Goals
- Long-term goals require prolonged time to achieve, often linked to discharge.
- Short-term goals can be completed in a designated timeframe.
Cognitive, Psychomotor, and Affective Outcomes
- Cognitive: Increases in patient knowledge.
- Psychomotor: Development of new skills by the patient.
- Affective: Changes in patient beliefs, values, and attitudes.
Implementing Care
- Reassess patient status regularly to adapt interventions as needed.
- Monitor responses to interventions for timely adjustments to the care plan.
Variables Influencing Care Plan Implementation
- Patient-related factors, nurse competencies, available resources, standards of care, research findings, and ethical/legal standards.
Importance of Ongoing Data Collection
- Continuous monitoring of patient responses informs necessary updates to the care plan.
Reassessment After Interventions
- Critical for determining the effectiveness of interventions and patient progress towards goals.
Patient Noncompliance
- Reassess strategies if patients are uncooperative, identify reasons for noncompliance or reevaluate the care plan.
Delegating Nursing Interventions
- Risks associated with fewer nurses caring for sicker patients while managing unlicensed assistive personnel performing previously professional tasks.
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