ncm long kwuis

• Planning – Deliberate, systematic, problem-solving phase of nursing process
• Nursing interventions – Treatment that a nurse performs to enhance patient/client outcomes
• Initial Planning - Develops initial comprehensive plan of care and begun after initial assessment
• Discharge Planning

  • Process of anticipating and planning for needs after discharge

  • Addressed in each client's care plan

  • Begins at first client contact

  • Involves comprehensive and ongoing assessment
• •Informal nursing care plan – A strategy for action that exists in nurse's mind
• Formal nursing care plan – Written or computerized guide
• Ongoing Planning

  • Done by all nurses who work with the client

  • Individualization of initial care plan

  • At the beginning of a shift

  – Determine whether client's health status has changed

  – Set priorities for client's care during shift

  • At the beginning of a shift

  – Decide which problems to focus on during shift – Coordinate nurse's activities so that more than one problem can be addressed at each client contact
• Standardized care plan – A formal plan that specifies actions for a group of clients with common needs
• Individualized care plan – Tailored to meet the unique needs of a specific client
• Protocols – Indicate actions commonly required for a particular groups of clients – May include both primary care provider's orders and nursing interventions
• Standardized care plans

  – Kept with client's individualized care plan, then permanent medical record

  – Provide detailed interventions

  – Written in the nursing process format
• Policies and procedures

  – Developed to govern handling of frequently occurring situations

  – Cover situations pertinent to client care
• Student Care Plans

  – Rationale

  – Concept maps
• Rationale

  ▪ Evidence-based principle given as the reason for selecting a particular nursing intervention
• Concept maps

  ▪ Visual tool in which ideas or data are enclosed in circles or boxes with relationships indicated by lines or arrows
• Computerized Care Plans

  – Create and store nursing care plans

  – Can be accessed at a centrally located terminal at nurses' station or in clients' rooms

  – Appropriate diagnoses selected from a menu suggested by the computer
• Multidisciplinary (Collaborative) Care Plans

  • Also known as collaborative care plans or critical pathways

  • Sequence care that must be given on each day during projected length of stay for each condition • Usually organized with a column for each day listing interventions and outcomes for that day

  • Includes medical treatments to be performed by other providers
• High priority (life-threatening)
• Medium priority (health-threatening)
• Low priority (developmental needs)
• Setting Priorities

  • Establishing a preferential sequence for addressing nursing diagnoses and interventions
• Goals – Broad statements about the client's status
• Desired outcomes – More specific, observable criteria used to evaluate whether goals have been met
• Factors to consider

  – Client's health values and beliefs

  – Client's priorities

  – Resources available to nurse and client

  – Urgency of the health problem

  – Medical treatment plan
• The Nursing Outcomes Classification (NOC)

  – Taxonomy for describing client outcomes that respond to nursing interventions

  – Outcomes broadly stated and conceptual
• Types of Nursing Interventions

  – Independent interventions

  – Dependent interventions

  – Collaborative interventions
• Independent interventions

  ▪ Activities nurses are licensed to initiate (i.e., physical care, ongoing assessment)
• Dependent interventions

  ▪ Activities carried out under primary care provider's orders or supervision, or according to specified routines
• Collaborative interventions

  ▪ Actions nurse carries out in collaboration with other health team members

  ▪ Reflect overlapping responsibilities of healthcare team
• Level 1 - Domains

  Level 2 - Classes

  Level 3 - Interventions