FUNDA 1

• Planning


  The nurse collaborates with the patient and the family and the rest of the health care team to determine the urgency of identifying problems and prioritizing patient needs
• Types of Planning


  • Initial Planning
  • Ongoing Planning
  • Discharge Planning
• Initial Planning


  Done by the nurse who conducts the admission assessment. Usually, the same nurse would be the one to create the initial comprehensive plan of care
• Ongoing Planning


  Done by the nurses who work with the client. As a nurse obtains new information and evaluates the client's responses to care, they can individualize the initial care plan further. An ongoing care plan also occurs at the beginning of the nurse's shift
• Discharge Planning


  The process of anticipating and planning for needs after discharge
• Discharge Planning Process


  1. Start discharge planning for all clients when they are admitted to any healthcare setting

  2. Involve the client and the client's family or support persons in the planning process

  3. Collaborate with other healthcare professionals as needed to ensure that biopsychosocial, cultural, and spiritual needs are met
• Setting Priorities


  The ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions
• Factors to consider in setting priorities


  • Client's Values and Beliefs
  • Client's Priorities
  • Resources Available
  • Urgency of Health Problem
• Levels of Priorities


  • High - If untreated, it may result in harm to patients or others. Consider Maslow's Hierarchy of Needs
  • Intermediate - Non-emergent, non-life threatening needs of the patients
  • Low - May not always be related to a specific illness but affect the patient's future well-being
• Goals


  Ultimate outcome
• Outcomes


  Measurable changes that must be achieved to reach a goal
• Patient-Centered Goal


  Reflects a patient's highest possible level of wellness and independence in function. It is realistic and based on patient needs, abilities, and resources. It is focused on PATIENT's specific behavior NOT the nurse's goal or interventions
• Nursing-Sensitive Patient Outcome


  A measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions, such as: reduction in pain frequency and severity
• Components of Goal/Desired Outcome Statement

  • Subject - a noun (client, any part of the client)
  • Verb - specifies an action the client is to perform
  • Conditions/Modifiers - added to the verb to explain (what, where, when, how?)
  • Criterion of Desired Outcome - the level at which client will perform specified behavior (time, speed, accuracy, distance, and quality)
• SMART Goal


  A goal that is Specific, Measurable, Achievable, Relevant, and Time-bound
• Nursing Intervention


  Any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Must be evidenced-based. This includes direct and indirect care measures aimed at individuals, families and communities
• Categories of Nursing Intervention

  • Independent (Nurse-initiated) - Actions that a nurse can perform without supervision or direction from others
  • Dependent (Healthcare Provider-initiated) - Actions that require an order from the health care provider (doctor)
  • Interdependent (Collaborative) - Therapies that require the combined knowledge, skill and expertise of multiple health care providers
• Factors in Choosing Intervention

  • Desired patient outcome
  • Characteristics of the nursing diagnosis
  • Research base knowledge for the intervention
  • Feasibility for doing the intervention
  • Acceptability to the patient
  • Nurse's competency
• Errors in Writing Intervention

  • Failure to precisely or completely indicate nursing actions (perform exercise on a lower extremity)
  • Failure to indicate frequency (administer pain medication)
  • Failure to indicate quantity (irrigate would once shift)
  • Failure to indicate method (change patient dressing daily)
• Nursing Care Plan


  Includes nursing diagnoses, goals and expected outcomes, specific nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient's clinical needs and situation. This may be subject to revision when the patient's status changes