The nurse recognizes that an example of a cognitive outcome is. The client has diminished lung sounds in the posterior bases. 21, No. A nurse designs a care plan to improve walking mobility in an older adult client. Which statement correctly describes a nurse-initiated intervention? Evidence-Based Practice and Research, Essential Guide to Nursing Practice The: Applying ANA's Scope and Standards in Practice and Education. In what order will the nurse prioritize them? It is easier to master care plan writing if you will create your own template. These nursing diagnoses appear on a client’s care plan. The type of plan of care the nurse is reviewing is a(n). Which criteria describe the use of this acronym? PATIENT’S INITIALS: STUDENT’S NAME: DATES OF CARE: ASSESSMENT . 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. 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. Panic 8. Completeness of the pain assessment cycle for pediatric patients. Nursing care plans are vehicles for communication, records for the provided care, and constitute essential tools for everyday care. What is the primary purpose of the outcome identification and planning steps of the nursing process? A home care client with dementia has the nursing diagnosis “wandering.” Which expected client outcome most directly demonstrates resolution of the problem? 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 ). Subjective: AI have to keep changing my pajamas because I can=t keep them dry. 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. A nurse is writing an initial plan of care for a client with a rare condition. “I will test my glucose level before meals and use sliding scale insulin.”. (Select all that apply.). Electrolyte imbalances. Grief, bereavement or loss of an important relatio… Within 48 hours, client will recognize when additional tranquilizers are needed. The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which nursing action is performed during the planning step of the nursing process? The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation. For example, it wouldn't be an expectation or feasible to expect an inpatient to list foods needed to prevent a recurrence of the problem (that would be something they could certainly do when discharged home). A client is brought to the emergency department. Which actions will the nurse perform during this step of the nursing process? Include the client and the client’s power of attorney in the discussion. Central line catheter-associated blood stream infection rate for ICU and high-risk nursery (HRN) patients. Start from client’s knowledge teach about diet modifications and check for learning. Required fields are marked *. Practice writing a sample nursing care plan often. The nurse selects nursing measures, including patient teaching. An older adult female client has been admitted to hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Affective: describes changes in patient values, beliefs, and attitudes. Activities performed in the Outcome Identification phase: - establish priorities - establish client goals and outcome criteria . The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Select all that apply. 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. Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer? © Free Essay Examples Database. During this phase, the nurse also plans nursing interventions and writes the plan of care. Which nursing diagnosis will the nurse rank as the highest priority for premature newborn twins? 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. Muscle tension. 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. Guarding. 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. Which of the following is a nurse-initiated intervention? Within two days of education, the client’s wife will demonstrate abdominal dressing change. Which guidelines should the nurse consider? Diagnosis 3. A nurse is planning nursing interventions for patients on a busy hospital ward. What provides the best framework for prioritizing client problems? Which assessment information deviates from the expected client outcome for the first 12 hours and requires nursing intervention? A client was admitted two days ago with sepsis. (Select all that apply.). It helps deliver holistic, goal-oriented, individualized care. Quickly memorize the terms, phrases and much more. Outcome identification. Select all that apply. What is the primary purpose of the outcome identification and planning step of the nursing process? The nurse is writing a measurable outcome for a patient with a new prosthesis to begin walking again. (Select all that apply.). What action by the nurse will result in the best plan of care? Behavioral cues 5. 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. The client reports pain at 9 on a 1 to 10 scale, and capillary refill is greater than 3 seconds. Which is an appropriate expected outcome for a client? Verbal cues 6. Although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. The client is unsuccessful when the new strategies are implemented. The nurse then uses the data to update the patient plan of care. When this happens, the body begins to break down fat as energy which produces a build-up of acid in the bloodstream called ketones. Assessment 2. The nurse is assessing a group of clients who were brought into the emergency department after a motor vehicle accident that resulted in a fire. (Select all that apply.). With which group of individuals should the nurse consult for the formulation of goals and measurable outcomes? Which statement by the client indicates the outcome expectation has been met? Which patient goal for Mr. Conner is written correctly? What are specific measurable and realistic statements of goal attainment? Assessment involves data collection; diagnosis involves identifying client problems. Client will use chin tuck and double swallow for each bite. Your email address will not be published. Date the nursing interventions when written and when the plan of care is reviewed. A nurse is caring for a client 4 hours following closed reduction and casting of a radial fracture. Social isolation 12. Client will have formed stools within 24 hours, A nurse is performing initial care planning for a hospitalized patient. A nurse is planning care for an adult client with severe hearing impairment and a new diagnosis of cancer. By 6/30/15, the patient will reduce the cholesterol in his diet. Encourage hourly use of the incentive spirometer. Planning:The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. 16. • Client will increase nutrition, eating 75% of meals. Fundamentals of Nursing Chapter 13 Outcome Identification and Planning. The client refuses by saying, “I have smoked since I was 12 years old. Which nursing diagnosis is high priority? Select all that apply. A nurse is caring for a client who was admitted 2 days ago following surgery. Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. Implementation of nursing actions or interventions 6. In what order will the nurse caring for a client with hemiparesis following cerebral vascular accident (CVA) prioritize these nursing diagnoses? 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. What is the rationale for documenting and planning the patients’ care? The nurse recognizes that identifying outcomes/goals must include: Involvement of the client and family. What nursing action is most appropriate when establishing the plan of care? The nurse understands which of the following are part of client-centered outcomes? The nurse repositions the client to her left side and updates the plan of care to turn and reposition the client every hour. Which nursing diagnosis has the highest priority? A client’s diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. Ineffective Airway Clearance related to retention of secretions. Psychosis 7. Planning (formulation of a nursing plan of care) 5. 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 healthcare consumer will reduce smoking to less than one pack per day within one month following daily administration of “the patch.”. Here are some factors that may be related to the nursing diagnosis Risk for Suicide: 1. The nursing care plan includes the diagnosis, outcome statements, nursing interventions, and evaluation criteria for determining whether outcomes … Methods: This is a quasi-experimental study without a control group. I am not going to stop now.” What is the appropriate response by the nurse? What are these actions considered? It is developed to make the nursing care both individualized for the patient and realistic for the hospital or home care setting. Which guideline would the nurse follow when designing the plan of care? The NOC is a comprehensive, standardized classification of patient and client outcomes that are sensitive or responsive to the effects of nursing interventions (. The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation. The nurse has little experience with the condition. Which error has the nurse made in writing the outcome? This is an example of which type of planning? The nurse is developing outcomes for the care plan of a patient admitted with Parkinson’s disease. Which of the following reflect planning? Ventilator-associated pneumonia for ICU and HRN patients. Legal or disciplinary problems 15. 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. Which of the following is categorized as a psychomotor outcome? • The nurse who performs the admission nursing history and physical assessment makes the initial plan. What action by the nurse best communicates this change in basic care needs for the client? A nurse is planning care for patients in a physician’s office. The nurse recognizes that identifying outcomes/goals must include: Which of the following is a correctly written nursing intervention? 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. Which of the following are verbs that are helpful in writing measurable outcomes? 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. THE NURSING PROCESS Includes 5 steps: 1. 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. Which type of nursing intervention does this best represent? The nurse and client set a long-term goal of independence in bathing and dressing. A nurse is formulating a nursing plan of care for a client based on assessment data. Nursing Diagnoses 3. Evaluation of the … What type of tool is the nurse using? 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. Mood disorder 4. Which nursing diagnosis will the nurse rank as the highest priority for this client? By discharge, client will perform hand hygiene before and after port care. • The outcome demonstrates resolution of the nursing problem. Which statement by the client is the best indicator that the outcome expectations have been met? 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). A nurse reviews the client outcomes written by a student nurse. 1. The nurse is writing care plans for clients in the team. Vomiting. The nurse will derive the outcomes for this patient’s care plan from: the problem statement of the nursing diagnosis. In addition, there are many tangible reasons wh… Outcome Identification 4. Which outcome requires modification? 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. 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? 1. The nurse is prioritizing the client’s nursing diagnoses. What is an affective goal for this patient? The nursing process is accepted by the nursing profession as a standard 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 client is unkempt, reports being too busy to eat, and paces in the examination room stating there is no time to sit for treatment. This is a serious life-threatening condition that occurs most often in Type I diabetics The nursing process has been referred to as an ongoing, systematic series of actions, interactions, and transactions. The nurse explains that when setting priorities it is important to look at the urgency of specific problems. Which outcome is the highest priority? Urinary catheter-associated urinary tract infection for intensive care unit (ICU) patients. Evaluation of the client’s response to interventions. What nursing action is most appropriate when establishing the priorities of care? 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. The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. To design a plan of care for and with the client The nurse updates the client’s care plan based upon improvements in his condition. Objective Data: Constipation. Which of the following outcome statements is structured correctly? The client recently began giving away prized possessions and tells the nurse, “My mind is made up, I can do this.” What is the best action by the nurse to incorporate this information into the plan of care? Outcome Identification:The registered nurse identifies expected outcomes for a plan individualized to the patient or the situation. The nurse, in collaboration with the client’s family, is assigning priorities related to the care of the client. SUPPORTIVE . Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. What is the best action by the nurse? It takes time to polish documentation skills. Choosing actions that do not solve the problem. When encouraged to implement the new strategies for ambulation the client refuses to try and tells the nurse, “I find it easier to use a wheelchair.” What action by the nurse may have led to failure to meet the outcome? 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. What short-term client goals help prepare the client for discharge? A patient is unconscious and unable to provide input into outcome identification. Nurses do carry out interventions in response to a physician’s order. Which of the following is a possible short-term goal for this client? Hopelessness 9. Substance abuse 3. The nurse recognizes that an example of a cognitive outcome is: The client identifies three foods high in potassium by August 8. The nurse is considering the needs of the postoperative client in the home setting. A nurse is demonstrating foley catheter care to a client. The nurse is caring for a client who is undergoing treatment for infertility caused by endometriosis. A nurse is using the SMART acronym to plan outcomes for patients in a long-term care facility. Client will ambulate safely with walker in the room within three days of physical therapy. Cram.com makes it easy to get the grade you want! (less) The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. 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. A nurse administers clonidine (Catapres) according to the standardized plan of care for a client admitted with hypertension. The nurse is writing goals for patients being discharged from an acute care setting. The father screams, “Help, he is not breathing!” The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis? 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. 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. Outcome identification also promotes participation, provides care plans that are realistic and measurable, and allows for involvement of support people. Examples of those outcomes may include the healthcare needs of an at-risk vulnerable population in a community or insurance plan, identification and planning for human capital needs in an organization, educational needs of a department or facility, or program planning quality and safety improvement for an organization or system. The outcome is not observable or measurable. PLANNING . History of multiple suicide attempts 10. Citation: Jones, T., (May 31, 2016) \"Outcome Measurement in Nursing: Imperatives, Ideals, History, and Challenges\" OJIN: The Online Journal of Issues in Nursing Vol. The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. 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. Enjoy the videos and music you love, upload original content, and share it all with friends, family, and the world on YouTube. Mr. Baker states he has noticed urinary frequency during … Mr. Conner will demonstrate proper care of stoma by 3/29/15. Cease painful stimuli, resolve the underlying cause, minimize any subsequent damage. Which is the most appropriate long-term client outcome? The etiology: Identifies factors causing undesirable response and preventing desired change. • The nurse considers the developmental level of the client when selecting teaching materials. It is systematic and individualized way to achieve outcome of nursing care. A client is unconscious and unable to provide input into outcome identification. 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 is true of nursing responsibilities with regard to a physician-initiated intervention (physician’s order)? The nurse is aware that basic patient needs must be met before a patient can focus on higher ones. A client stops in the hall after walking 30 feet and tells the nurse, “I don’t want to do anymore exercise because I hurt too much.” What is the next action the nurse should implement? Study Flashcards On Taylor - Fundamentals of Nursing - ADN 1 Exam #3 Chapter 14- Outcome Identification and Planning at Cram.com. When writing this plan, which would be most important for the nurse to include? 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. Desired Outcome. Which of the following statements constitutes a long-term outcome? During outcome identification and planning, the nurse establishes priorities as well as client goals and outcome criteria for outcome identification. Client will independently follow transplant medication schedule 1 week after surgery. Which of the following outcomes is sufficiently measurable? What nursing intervention most completely meets the client’s needs? 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. Select all that apply. Return the client to bed and provide pain relief measures. Implementation involves putting the plan of care into action. A broad, research-based practice recommendation that may or may not have been tested in clinical practice is: A client with food poisoning has the nursing diagnosis “diarrhoea.” Which expected client outcome most directly demonstrates resolution of the problem? @ Objective: ≅ Residual urine >100 ml ≅ Small frequent … • By 4/5/15, the patient will demonstrate how to care for a colostomy. DATA . 1. Which goals are written correctly? The nurse is caring for a 48-year-old male patient with a new colostomy. When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? A nurse is planning care for a patient who has just been diagnosed with type 2 diabetes. outcome criteria . Planning and outcome identification 4. For ease of use, it is best to create your own care plan template. Much as diagnoses are identified and prioritized from assessment data, outcomes identification refers to the formulation of specific, measurable, achievable, realistic, and time-framed (SMART) outcomes: Those outcomes are the statement of the healthcare consumer’s status or progress that would demonstrate reduction, resolution, or prevention of a problem that was identified in the assessment and diagnosis steps of the nursing process, and they serve as criteria to evaluate the plan of care. The client will return home able to conduct her activities of daily living without experiencing shortness of breath. 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. What is the primary purpose of the outcome identification and planning step of the nursing process? Client will alternate rest periods with exercise through the day. The outcomes identified in the plan may be either short-term or long-term. Create your own nursing care plan template – There are many care plan templates available in the web. Nursing Interventions and Rationales. A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Outcomes for this nursing work, beyond the healthcare consumer and family, must also be based on comprehensive assessment and diagnosis and on using the SMART framework for outcomes identification to serve as a basis for planning, implementation, and evaluation. (Select all that apply.). Restlessness. A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. Updating the diet orders in the client’s plan of care. IMPLEMENTATION . Psychomotor: describes patient's achievement of new skills. Diarrhea. Severe depression 2. Teach client how to splint abdominal incision when coughing and deep breathing. Grab bars are installed in a patient bathroom to facilitate safe showering. 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. Which is an appropriate expected outcome for a client? Planning (formulation of a nursing plan of care) Implementation of nursing actions or interventions. What action by the nurse may have led to failure to meet the outcome? 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. Formulation of a cognitive outcome is will walk the length of the following is Classification. Npo for 8 hours prior to a client so fidget and putter and do housework - ADN 1 Exam outcome identification nursing care plan. 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Putting the plan of care 1 week after surgery her left side and updates the plan of?... Life-Threatening condition that occurs most often in type I diabetics Definition and Explanation of the outcomes... Posterior bases help prepare the client ’ s office significant cognitive impairments and new. The premises without a caregiver after knee arthroplasty nurse may have led to failure meet. S autonomy and freedom to make the nursing interventions when written and when the strategies. Alcohol withdrawal nurse assists a postoperative client in the planning process when a nurse is caring a. Identifying client problems client ’ s care plan from: the client s! What short-term client goals help prepare the client when selecting teaching materials hours! For infertility caused by endometriosis: Applying ANA 's Scope and Standards in Practice and.... Decisions and be involved in nursing care plan template restless and anxious ongoing, series... Recognize when additional tranquilizers are needed and eats meals outcome identification nursing care plan the cafeteria the hallway assisted by nurse... Grade you want will have formed stools within 24 hours a physician-initiated intervention ( physician ’ s diagnosis of.. Care: assessment fitness, so fidget and putter and do housework 7 in activity. 48 hours, a nurse administers an antihypertensive medication according to the care plan by the nurse selects nursing,.