• The outcome demonstrates resolution of the nursing problem. A client is required to be NPO for 8 hours prior to a test scheduled for tomorrow. 21, No. outcome criteria . Within 48 hours, client will recognize when additional tranquilizers are needed. The NOC is a comprehensive, standardized classification of patient and client outcomes that are sensitive or responsive to the effects of nursing interventions (. When should discharge planning to address ADLs begin for this client? 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. Planning (formulation of a nursing plan of care) 5. Select all that apply. The client reports pain at 9 on a 1 to 10 scale, and capillary refill is greater than 3 seconds. Fundamentals of Nursing Chapter 13 Outcome Identification and Planning. Muscle tension. What short-term client goals help prepare the client for discharge? • The nurse who performs the admission nursing history and physical assessment makes the initial plan. What intervention by the nurse would be most effective in helping the client attain this goal? Which guidelines should the nurse consider? The nurse, in collaboration with the client’s family, is assigning priorities related to the care of the client. Start from client’s knowledge teach about diet modifications and check for learning. In what order will the nurse caring for a client with hemiparesis following cerebral vascular accident (CVA) prioritize these nursing diagnoses? What would be the most appropriate action for the nurse to take? A father runs into the emergency room with his 18-month-old son in his arms. Poor support system, loneliness 14. Which is an appropriate expected outcome for a client? What is the rationale for documenting and planning the patients’ care? Risk for Suicide Care Plan Desired goals and Outcomes A nursing care plan for suicidal patients involves providing them with a safe environment to initiate a no-suicide attitude, creating a support system and ensure that there is close supervision until the patient departs from the idea. 1. According to Maslow’s hierarchy of human needs, which example would be the highest priority for a patient after physiologic needs have been met? Which nursing diagnosis will the nurse rank as the highest priority for this client? By 6/30/15, the patient will reduce the cholesterol in his diet. A nurse is caring for a client who began taking the antidepressant paroxetine (Paxil) 2 weeks ago. Select all that apply. 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 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. Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender. If this is a nursing care plan for an in-patient, then you would want to ensure the nursing care plan is geared towards that type of situation. What nursing intervention most completely meets the client’s needs? Mr. Baker states he has noticed urinary frequency during … The nurse selects nursing measures, including patient teaching. In the past, healthcare outcomes that were determined to be nursing sensitive were those that were influenced by and improved by a greater quantity or quality of nursing care. The nurse and client set a long-term goal of independence in bathing and dressing. 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. When writing this plan, which would be most important for the nurse to include? The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. Fry proposed to nurses that: \"the first major task in our creative approach to nursing is to formulate a nursing diagnosis and design a plan which is individual and which evolves as a result of a synthesis of needs\" (p. 302). The nursing process is accepted by the nursing profession as a standard (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. Which assessment information deviates from the expected client outcome for the first 12 hours and requires nursing intervention? 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. The nurse is writing care plans for clients in the team. The client has diminished lung sounds in the posterior bases. A 63-year-old client in the ICU with a nursing diagnosis of risk for impaired skin integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. Outcome Identification:The registered nurse identifies expected outcomes for a plan individualized to the patient or the situation. A client is brought to the emergency department. Outcome identification also promotes participation, provides care plans that are realistic and measurable, and allows for involvement of support people. All rights reserved. Which is the most appropriate long-term client outcome? Grab bars are installed in a patient bathroom to facilitate safe showering. The nurse explains that when setting priorities it is important to look at the urgency of specific problems. Cease painful stimuli, resolve the underlying cause, minimize any subsequent damage. Client will alternate rest periods with exercise through the day. Which of the following is categorized as a psychomotor outcome? The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. A nurse is caring for a client who was admitted 2 days ago following surgery. Psychomotor: describes patient's achievement of new skills. A nurse is planning care for a patient who has just been diagnosed with type 2 diabetes. 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. Rebound tenderness. 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. Client will independently follow transplant medication schedule 1 week after surgery. What is the best action by the nurse? The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. Abdominal Pain Nursing Care Plan. The expected outcome for a client with a new diagnosis of diabetes mellitus (DM) is: client will describe appropriate actions when implementing the prescribed medication routine. 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. The Nursing Outcomes Classification (NOC) is a classification system which describes patient outcomes sensitive to nursing intervention. It takes time to polish documentation skills. Cram.com makes it easy to get the grade you want! Definition and Explanation of the Standard The nursing community has defined an outcome as an individual's, family's,… Here are some factors that may be related to the nursing diagnosis Risk for Suicide: 1. Your email address will not be published. IMPLEMENTATION . Quickly memorize the terms, phrases and much more. 16. Care Plans: A Path to Driving Better Outcomes 7 in light activity increases fitness, so fidget and putter and do housework. However, while embracing this culture may seem like a hectic task, there are solid studies that show that it indeed has lots of benefits. Which nursing diagnosis is high priority? 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. Nurse-initiated interventions are derived from the nursing diagnosis. Central line catheter-associated blood stream infection rate for ICU and high-risk nursery (HRN) patients. The nursing care plan includes the diagnosis, outcome statements, nursing interventions, and evaluation criteria for determining whether outcomes … The father screams, “Help, he is not breathing!” The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis? Client will have formed stools within 24 hours, A nurse is performing initial care planning for a hospitalized patient. Which criteria describe the use of this acronym? • By 4/5/15, the patient will demonstrate how to care for a colostomy. It is vital that a recognized nursing assessment framework is used in practice to identify the patient's* problems, risks and outcomes for enhancing health. The nurse is also involved in identifying outcomes to design plans for improvement in direct and indirect nursing work, such as with groups, communities, populations, organizations, and systems. The etiology: Identifies factors causing undesirable response and preventing desired change. • At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. Behavioral cues 5. Study Flashcards On Taylor - Fundamentals of Nursing - ADN 1 Exam #3 Chapter 14- Outcome Identification and Planning at Cram.com. Legal or disciplinary problems 15. The nurse updates the client’s care plan based upon improvements in his condition. A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis “impaired swallowing.” Which expected client outcome is most effective? Select all that apply. 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 ). Client will use chin tuck and double swallow for each bite. For ease of use, it is best to create your own care plan template. The nurse is prioritizing the client’s nursing diagnoses. Fundamentals of Nursing Chapter 13 Outcome Identification and Planning. What action by the nurse best communicates this change in basic care needs for the client? Inpatient care 13. Which of the following is a possible short-term goal for this client? This is an example of which type of planning? Which client should the nurse give the highest priority for care? A nurse administers colchicine according to the standardized plan of care for a client admitted with acute gouty arthritis of the right great toe. 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: condition. A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. By discharge, client will perform hand hygiene before and after port care. What action by the nurse will result in the best plan of care? I have to wait 2 months before I can practice walking, again.” What is the highest priority nursing diagnosis? It is systematic and individualized way to achieve outcome of nursing care. Hopelessness 9. Vomiting. 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. However, in recent years the concept of nursing care plans has been in the limelight as some healthcare experts argue that it is a mere time-waster. The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation. What is the best modification to the care plan by the nurse? A nurse reviews the client outcomes written by a student nurse. It is composed of setting priorities and establishing outcomes. Urinary catheter-associated urinary tract infection for intensive care unit (ICU) patients. Which of the following statements constitutes a long-term outcome? Restlessness. During outcome identification and planning, the nurse establishes priorities as well as client goals and outcome criteria for outcome identification. Create your own nursing care plan template – There are many care plan templates available in the web. Which assessment information deviates from the expected client outcome for the first 24 hours and requires nursing intervention? What is the primary purpose of the outcome identification and planning steps of the nursing process? The nurse has little experience with the condition. 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 . A nurse is planning nursing interventions for patients on a busy hospital ward. THE NURSING PROCESS Includes 5 steps: 1. Verbal cues 6. The nurse then uses the data to update the patient plan of care. Which nursing diagnosis will the nurse rank as the highest priority for premature newborn twins? Which guideline would the nurse follow when designing the plan of care? 2, Manuscript 1.DOI: 10.3912/OJIN.Vol21No02Man01Key Words: Nurse Sensitive Indicators, nursing outcomes, nursing process measures, quality assessment, quality metrics, quality measures, outcomes management, outcomes research, Minimum Nursi… Assessment involves data collection; diagnosis involves identifying client problems. Ineffective Airway Clearance related to retention of secretions. The nurse recognizes that identifying outcomes/goals must include: Which of the following is a correctly written nursing intervention? The nursing process is an interactive, problem-solving process. To design a plan of care for and with the client The client is unsuccessful when the new strategies are implemented. A nurse is planning care for an adult client with severe hearing impairment and a new diagnosis of cancer. Evaluation of the client’s response to interventions. Which of the following outcome statements is structured correctly? Choosing actions that do not solve the problem. Assessment 2. What is a correctly written goal for this client? The nurse is caring for a 48-year-old male patient with a new colostomy. Which components must be included in the outcome? A nurse is planning care for patients in a physician’s office. What is the primary purpose of the outcome identification and planning step of the nursing process? Which intervention performed by the nurse is most appropriate for assisting a client in meeting physiologic needs based on Maslow’s Hierarchy of Needs? The nurse recognizes that an example of a cognitive outcome is: The client identifies three foods high in potassium by August 8. Return the client to bed and provide pain relief measures. A client’s diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. Subjective Data: Abdominal pain. Although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. With which group of individuals should the nurse consult for the formulation of goals and measurable outcomes? Suicidal ideation or plan 11. Assessment 2. © Free Essay Examples Database. 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. Stimuli, resolve the underlying cause, minimize any subsequent damage a physician-initiated intervention ( ’... Using the SMART acronym to plan outcomes for patients in a physician ’ s care plan by the understands! That prescribes strategies and alternatives to attain expected outcomes for outcome identification nursing care plan in a ’! 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