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Foundations: Fundamentals of Nursing, Chapter 18, better Planning Nursing Care

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Grade levels:
College: Third year

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1

Collaborative interventions

interdependent interventions, therapies that require the knowledge, skill, and expertise of multiple health care professionals

2

consultation

Process in which the help of a specialist is sought to identify ways to handle problems in patient management or in planning and implementing programs.

3

critical pathways

Tools used in managed care that incorporate the treatment interventions of caregivers from all disciplines who normally care for a patient. Designed for a specific care type, a pathway is used to manage the care of a patient throughout a projected length of stay.

4

critical pathways

many health care facilities use __, which are multidisciplinary treatment plans, are patient care management plans that provide the multidisciplinary health care team with the activities and tasks to be put into practice sequentially (over time), their main purpose is to deliver timely care at each phase of the care process for a specific type of patient

5

dependent nursing interventions

Physician-initiated interventions are __, or actions that require an order from a physician or another health care professional.

6

expected outcome

a measurable criterion to evaluate goal achievement

7

goal

a broad statement that describes a desired change in a patient's condition or behavior

8

independent nursing interventions

nurse-initiated interventions are __, or actions that a nurse initiates

9

interdisciplinary care plans

is designed to improve the coordination of all patient therapies and communication among all disciplines. It includes contributions from all disciplines involved in patient care

10

long-term goal

an objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks, or months (e.g., "Patient will be tobacco free within 60 days").

11

nursing care plan

includes nursing diagnoses, goals and/or 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.

12

nursing-sensitive patient outcome

a measurable patient, family or community state, behavior, or perception largely influenced by and sensitive to nursing interventions

13

patient-centered goal

reflects a patient's highest possible level of wellness and independence in function. It is realistic and based on patient needs and resources, represents predicted resolution of a diagnosis or problem, evidence of progress toward resolution, progress toward improved health status, or continued maintenance of good health or function.

14

planning

Process of designing interventions to achieve the goals and outcomes of health care delivery.

15

priority setting

the ordering of nursing diagnoses or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions

16

scientific rationale

Reason why a specific nursing action was chosen based on supporting literature.

17

short-term goal

an objective behavior or response that you expect a patient to achieve in a short time, usually less than a week. In an acute care setting you often set goals for over a course of just a few hours

18

short

in acute care the focus is on __ term goals

19

high priority

typically revolve around safety, adequate oxygenation, and circulation. However, you must always consider each client's unique situation. These priorities can be physiological, psychological, or related to other basic human needs. Ex. risk for other-directed violence (safety), impaired gas exchange (airway status), decreased cardiac output (circulation)

20

intermediate priority

diagnosis involves the nonemergent, non-life threatening needs of the patient. Ex deficient knowledge and impaired physical mobility

21

low priority

may not be related to a specific illness or prognosis but may call for an intervention that affects the patient's future well-being. Many of these deal with the patient's long-term health care needs.

22

initial planning

involves the development of a preliminary care plan following the patient's initial assessment and initial selection of nursing diagnoses. This phase can be challenging due to the short length of patient stay.

23

ongoing planning

Involves continuous updating of the patient's plan of care. As the patient's condition changes, for better or worse, continual assessments need to be made, and revisions may be necessary. You're always looking at your patient and updating your plan of care

24

discharge planning

Starts when patient is admitted

25

involves the important aspects and preparations needed for the patient to go home.

no data

26

expected outcome

Criteria that will be evaluated in order to achieve your goal

27

goal

example of a __ is: Mr. Jacobs achieves pain relief by day of discharge

28

expected outcome

example of a(n) __ is: Mr. Jacobs reports a pain level of 3 or below by day of discharge. Or, Mr. Jacobs turns freely in the bed within 24 hours

29

NOC

used to have a common language within nursing (outcomes)

30

short-term goal

is what you expect the patient to achieve in a short period of time. Since hospital stays are shorter than before, these goals may last several hours to days.

31

long-term goal

are expected to be achieved in longer period of time....may not occur while hospitalized, may be post DC goal

32

expected outcomes

Determine when a specific, patient-centered goal has been met

33

measurable

expected outcomes must be __

34

sequential time frame

Expected outcomes should be written in a __

35

patient-centered

__ outcomes and goals reflect the client behavior and responses expected as a result of nursing interventions. The goal must be written to reflect the desires of the client rather than the nurse.

36

no

should you use terms such as "normal," "acceptable," or "stable" in goals?

37

time frames

enable nurses to help clients meet goals and make progress at a reasonable rate

38

nurse practice acts

each state has developed __ that delineates nursing interventions

39

nurse initiated interventions

most of these relate to ADLs, health education, and promotion and counseling

40

characteristics of nsg dx, goals and expected outcomes, evidence base for interventions, feasibility of the intervention, acceptability to the client, nurse's competency

six factors of interventions

41

kardex, standard care, computerized plan

the nursing plan of care can take place in many forms, such as:

42

nursing diagnoses, goals and expected outcomes, and nursing interventions

the nursing care plan includes:

43

nursing care plan

helps to ensure continuity of care by all nurses

44

student care plans

help you organize your plan for the day as a nursing student. Helps you to apply the theory you learned.

45

institutional care plan

is part of the patient's legal record. Health care facilities use some type of electronic health record, and the care plan is part of the record.

46

medical, nursing

most critical pathways are based on the __ diagnosis and not the __ diagnosis

47

pathway

the __ details day-to-day activities a client must achieve before discharge

48

problem-solving

consultation is based on a __ approach

49

B, C

(Pain control is a priority, because it is severe and affects the patient's ability to rest after surgery and be able to perform necessary activities. A change in vital signs is a priority, and the change could be related to the patient's pain. However, because of the nature of surgery, the nurse has to reassess for any bleeding, which lowers blood pressure. Attending to the family is important to lend the patient needed support, but it is not the initial priority. Finally the nurse must attend to urgent patient needs before completing a report.)

A nurse is assigned to a patient who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment the nurse anticipates the need to monitor the patient's abdominal dressing, intravenous (IV) infusion, and function of drainage tubes. The patient is in pain, reporting 6 on a scale of 0 to 10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient. The nurse establishes priorities first for which of the following situations? (Select all that apply.)

A) The family comes to visit the patient.
B) The patient expresses concern about pain control.
C) The patient's vital signs change, showing a drop in blood pressure.
D) The charge nurse approaches the nurse and requests a report at end of shift.

50

A (Reconnect the drainage tubing)

(The priority is to reconnect the drainage tube. This can be done quickly and prevents fluid loss and reduces risk of infection spreading up into the tube. Next the nurse turns the patient for comfort. With 100 mL of fluid remaining, the nurse has time to perform these tasks. The nurse can inspect the IV dressing last, after going to obtain the next IV fluid bag.)

A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the intravenous (IV) line, and the patient asking to be turned. Which of the following does the nurse perform first?

A) Reconnect the drainage tubing
B) Inspect the condition of the IV dressing
C) Improve the patient's comfort and turn onto her side.
D) Obtain the next IV fluid bag from the medication room

51

B, C

(The skin remaining intact is an appropriate goal for the patient's at-risk diagnosis. A return of normal bowel functioning is also appropriate since it indicates removal of a risk factor. Turning the patient is an intervention skin condition improving by discharge is a poorly written goal that is not measurable.)

no data

52

no data

A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of risk for impaired skin integrity. Which of the following goals are appropriate for the patient? (Select all that apply.)

A) Patient will be turned every 2 hours within 24 hours.
B) Patient will have normal bowel function within 72 hours.
C) Patient's skin will remain intact through discharge.
D) Patient's skin condition will improve by discharge.

53

D (Indicates when the patient is expected to respond in the desired manner)

(The time frame indicates when you expect a response to your nursing interventions. Time frames help to organize priorities but do not indicate which problem is most important. Time frames for outcomes are not used to gauge the time it takes to complete interventions, and they are unrelated to a nurse's work schedule.)

Setting a time frame for outcomes of care serves which of the following purposes?

A) Indicates which outcome has priority
B) Indicates the time it takes to complete an intervention
C) Indicates how long a nurse is scheduled to care for a patient
D) Indicates when the patient is expected to respond in the desired manner

54

C (Patient will achieve glucose control.)

(It will take time for the patient who is medically unstable to achieve glucose control. Explaining the relationship of insulin to blood glucose control and self-administering insulin are short term goals and should be met before discharge. Describing steps for preparing insulin in a syringe is not a goal but an outcome statement for the goal that the patient will self-administer insulin.)

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. Which of the following patient care goals are long term?

A) Patient will explain relationship of insulin to blood glucose control.
B) Patient will self-administer insulin.
C) Patient will achieve glucose control.
D) Patient will describe steps for preparing insulin in a syringe.

55

A, C, D

(A goal must be realistic and one that the patient has cognitive and sociocultural potential to reach. The nurse's competency does not influence the patient's goal. However, it may mean that the nurse must consult with a diabetes educator or a more qualified nurse before beginning instruction.)

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. What does the nurse need to determine before setting the goal of "patient will self-administer insulin?" (Select all that apply.)

A) Goal within reach of the patient
B) The nurse's own competency in teaching about insulin
C) The patient's cognitive function
D) Availability of family members to assist

56

D (Patient will report pain acuity less than 4 on a scale of 0 to 10.)

(Answer 4 is measurable because it is the only outcome statement that allows the nurse to obtain an actual measure of the patient's pain. The patient being pain free is a goal

no data

57

the patient having less pain is written vaguely, and the patient taking pain medication every 4 hours is an intervention.)

The nurse writes an expected-outcome statement in measurable terms. An example is:

A) Patient will be pain free.
B) Patient will have less pain.
C) Patient will take pain medication every 4 hours.
D) Patient will report pain acuity less than 4 on a scale of 0 to 10.

58

D (Consult with dietitian on initial foods to offer patient.)

(Providing frequent mouth care and controlling outside stimulation that triggers nausea are independent interventions. Maintaining an IV infusion and administering the rectal suppository are dependent interventions.)

A patient has the nursing diagnosis of nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions?

A) Provide frequent mouth care.
B) Maintain intravenous (IV) infusion at 100 mL/hr.
C) Administer prochlorperazine (Compazine) via rectal suppository.
D) Consult with dietitian on initial foods to offer patient.
E) Control aversive odors or unpleasant visual stimulation that triggers nausea.

59

1B, 2C, 3A

(The patient's oxygenation status is the priority in this situation. The patient's condition creates the risk for activity intolerance, making this an intermediate priority for which the nurse must monitor. Ineffective self-help management is a long-term goal that might be applicable if the patient has physical limitations at the time of discharge.)

A 72-year-old patient has come to the health clinic with symptoms of a productive cough, fever, increased respiratory rate, and shortness of breath. His respiratory distress increases when he walks. He lives alone and did not come to the clinic until his neighbor insisted. He reports not getting his pneumonia vaccine this year. Blood tests show the patient's oxygen saturation to be lower than normal. The physician diagnoses the patient as having pneumonia. Match the priority level with the nursing diagnoses identified for this patient:

Nursing Diagnoses
1. Impaired gas exchange _____
2. Risk for activity intolerance _____
3. Ineffective self-health management _____

Priority Level
a. Long term
b. Short term
c. Intermediate

60

(1) C, (2) D, (3) B, (4) A

An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: risk for fall, impaired physical mobility related to pain, and wandering related to cognitive impairment. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right.

Goals
1. Patient will ambulate independently in 3 days. _____
2. Patient will be injury free for 1 month. _____
3. Patient will be less agitated. _____
4. Patient will achieve pain relief. _____

Outcomes
a. Patient will express fewer nonverbal signs of discomfort.
b. Patient will follow a set care routine.
c. Patient will walk correctly using a walker.
d. Patient will exit a low bed without falling

61

C (During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient.)

(Creating a culture of blame does not support questioning, which is needed for good handoff communication. Talking about the patient's anxiety during handoff is patient centered and thus appropriate, referring to the EHR to review interventions ensures that essential information is included, and administering a pain medication before the report allows the nurse to be organized and uninterrupted during rounds.)

A nurse is preparing for change-of-shift rounds with the nurse who is assuming care for his patients. Which of the following statements or actions by the nurse are characteristics of ineffective handoff communication?

A) This patient is anxious about his pain after surgery

62

you need to review the information I gave him about how to use a patient-controlled analgesia (PCA) pump this evening.
B) The nurse refers to the electronic care plan in the electronic health record (EHR) to review interventions for the patient's care.
C) During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient.
D) The nurse gives her patient a pain medication before report so there is likely to be no interruption during rounding.

no data

63

B, D

(The statement "Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week" is not singular. The statement "Give patient liquid supplements 3 times a day" is an intervention.)

Which of the following outcome statements for the goal, "Patient will achieve a gain of 10 lbs (4.5 kg) in body weight in a month" are worded incorrectly? (Select all that apply.)
A) Patient will eat at least three fourths of each meal by 1 week.
B) Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week.
C) Patient will eat foods with high-calorie content by 1 week.
D) Give patient liquid supplements 3 times a day.

64

B (The patient and family need to be able to independently provide most of the health care.)

(A community-based health care setting such as home health must work with patients and their families to set goals and outcomes that ultimately lead to a plan that allows them to provide the majority of care themselves. Goals of care will not always be more long term

no data

65

goals will be short term and long term, depending on the patient's condition. Mutually setting goals with caregiving family members is true for any health care setting. The statement "The expected outcomes need to address what can be influenced by interventions" is incorrect

no data

66

the outcomes allow you to direct your evaluation of care.)

A nurse from home health is talking with a nurse who works on an acute medical division within a hospital. The home health nurse is making a consultation. Which of the following statements describes the unique difference between a nursing care plan from a hospital versus one for home care?

A) The goals of care will always be more long term.
B) The patient and family need to be able to independently provide most of the health care.
C) The patient's goals need to be mutually set with family members who will care for him or her.
D) The expected outcomes need to address what can be influenced by interventions.

67

C (The patient's wound will reduce in size to less than 4 cm -1 ½ inches- by day 4.)

(An outcome must have terms describing quality, quantity, frequency, length, or weight to allow for precise measurement. The statement "The patient's wound will reduce in size to less than 4 cm - 1 ½ inches - by day 4" identifies a specific wound size, which indicates a degree of healing. The outcome statements concerning the wound appearing normal and having less drainage are vague and not measurable. The statement "The patient's wound will heal without redness or drainage by day 4" has more than one outcome.)

Which outcome allows you to measure a patient's response to care more precisely?

A) The patient's wound will appear normal within 3 days.
B) The patient's wound will have less drainage within 72 hours.
C) The patient's wound will reduce in size to less than 4 cm (1 ½ inches) by day 4.
D) The patient's wound will heal without redness or drainage by day 4.

68

A, C

(The statements "Turn the patient regularly from side to back to side" and "Apply a pressure-relief device to bed" do not provide specific guidelines for the frequency or type of intervention. The other two options identify specific intervention methods.)

A nurse identifies several interventions to resolve the patient's nursing diagnosis of impaired skin integrity. Which of the following are written in error? (Select all that apply.)

A) Turn the patient regularly from side to back to side.
B) Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence.
C) Apply a pressure-relief device to bed.
D) Apply transparent dressing to sacral pressure ulcer.

69

Collaborative interventions

interdependent interventions, therapies that require the knowledge, skill, and expertise of multiple health care professionals

70

consultation

Process in which the help of a specialist is sought to identify ways to handle problems in patient management or in planning and implementing programs.

71

critical pathways

Tools used in managed care that incorporate the treatment interventions of caregivers from all disciplines who normally care for a patient. Designed for a specific care type, a pathway is used to manage the care of a patient throughout a projected length of stay.

72

critical pathways

many health care facilities use __, which are multidisciplinary treatment plans, are patient care management plans that provide the multidisciplinary health care team with the activities and tasks to be put into practice sequentially (over time), their main purpose is to deliver timely care at each phase of the care process for a specific type of patient

73

dependent nursing interventions

Physician-initiated interventions are __, or actions that require an order from a physician or another health care professional.

74

expected outcome

a measurable criterion to evaluate goal achievement

75

goal

a broad statement that describes a desired change in a patient's condition or behavior

76

independent nursing interventions

nurse-initiated interventions are __, or actions that a nurse initiates

77

interdisciplinary care plans

is designed to improve the coordination of all patient therapies and communication among all disciplines. It includes contributions from all disciplines involved in patient care

78

long-term goal

an objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks, or months (e.g., "Patient will be tobacco free within 60 days").

79

nursing care plan

includes nursing diagnoses, goals and/or 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.

80

nursing-sensitive patient outcome

a measurable patient, family or community state, behavior, or perception largely influenced by and sensitive to nursing interventions

81

patient-centered goal

reflects a patient's highest possible level of wellness and independence in function. It is realistic and based on patient needs and resources, represents predicted resolution of a diagnosis or problem, evidence of progress toward resolution, progress toward improved health status, or continued maintenance of good health or function.

82

planning

Process of designing interventions to achieve the goals and outcomes of health care delivery.

83

priority setting

the ordering of nursing diagnoses or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions

84

scientific rationale

Reason why a specific nursing action was chosen based on supporting literature.

85

short-term goal

an objective behavior or response that you expect a patient to achieve in a short time, usually less than a week. In an acute care setting you often set goals for over a course of just a few hours

86

short

in acute care the focus is on __ term goals

87

high priority

typically revolve around safety, adequate oxygenation, and circulation. However, you must always consider each client's unique situation. These priorities can be physiological, psychological, or related to other basic human needs. Ex. risk for other-directed violence (safety), impaired gas exchange (airway status), decreased cardiac output (circulation)

88

intermediate priority

diagnosis involves the nonemergent, non-life threatening needs of the patient. Ex deficient knowledge and impaired physical mobility

89

low priority

may not be related to a specific illness or prognosis but may call for an intervention that affects the patient's future well-being. Many of these deal with the patient's long-term health care needs.

90

initial planning

involves the development of a preliminary care plan following the patient's initial assessment and initial selection of nursing diagnoses. This phase can be challenging due to the short length of patient stay.

91

ongoing planning

Involves continuous updating of the patient's plan of care. As the patient's condition changes, for better or worse, continual assessments need to be made, and revisions may be necessary. You're always looking at your patient and updating your plan of care

92

discharge planning

Starts when patient is admitted, involves the important aspects and preparations needed for the patient to go home.

93

expected outcome

Criteria that will be evaluated in order to achieve your goal

94

goal

example of a __ is: Mr. Jacobs achieves pain relief by day of discharge

95

expected outcome

example of a(n) __ is: Mr. Jacobs reports a pain level of 3 or below by day of discharge. Or, Mr. Jacobs turns freely in the bed within 24 hours

96

NOC

used to have a common language within nursing (outcomes)

97

short-term goal

is what you expect the patient to achieve in a short period of time. Since hospital stays are shorter than before, these goals may last several hours to days.

98

long-term goal

are expected to be achieved in longer period of time....may not occur while hospitalized, may be post DC goal

99

expected outcomes

Determine when a specific, patient-centered goal has been met

100

measurable

expected outcomes must be __

101

sequential time frame

Expected outcomes should be written in a __

102

patient-centered

__ outcomes and goals reflect the client behavior and responses expected as a result of nursing interventions. The goal must be written to reflect the desires of the client rather than the nurse.

103

no

should you use terms such as "normal," "acceptable," or "stable" in goals?

104

time frames

enable nurses to help clients meet goals and make progress at a reasonable rate

105

nurse practice acts

each state has developed __ that delineates nursing interventions

106

nurse initiated interventions

most of these relate to ADLs, health education, and promotion and counseling

107

characteristics of nsg dx, goals and expected outcomes, evidence base for interventions, feasibility of the intervention, acceptability to the client, nurse's competency

six factors of interventions

108

kardex, standard care, computerized plan

the nursing plan of care can take place in many forms, such as:

109

nursing diagnoses, goals and expected outcomes, and nursing interventions

the nursing care plan includes:

110

nursing care plan

helps to ensure continuity of care by all nurses

111

student care plans

help you organize your plan for the day as a nursing student. Helps you to apply the theory you learned.

112

institutional care plan

is part of the patient's legal record. Health care facilities use some type of electronic health record, and the care plan is part of the record.

113

medical, nursing

most critical pathways are based on the __ diagnosis and not the __ diagnosis

114

pathway

the __ details day-to-day activities a client must achieve before discharge

115

problem-solving

consultation is based on a __ approach

116

B, C

(Pain control is a priority, because it is severe and affects the patient's ability to rest after surgery and be able to perform necessary activities. A change in vital signs is a priority, and the change could be related to the patient's pain. However, because of the nature of surgery, the nurse has to reassess for any bleeding, which lowers blood pressure. Attending to the family is important to lend the patient needed support, but it is not the initial priority. Finally the nurse must attend to urgent patient needs before completing a report.)

A nurse is assigned to a patient who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment the nurse anticipates the need to monitor the patient's abdominal dressing, intravenous (IV) infusion, and function of drainage tubes. The patient is in pain, reporting 6 on a scale of 0 to 10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient. The nurse establishes priorities first for which of the following situations? (Select all that apply.)

A) The family comes to visit the patient.
B) The patient expresses concern about pain control.
C) The patient's vital signs change, showing a drop in blood pressure.
D) The charge nurse approaches the nurse and requests a report at end of shift.

117

A (Reconnect the drainage tubing)

(The priority is to reconnect the drainage tube. This can be done quickly and prevents fluid loss and reduces risk of infection spreading up into the tube. Next the nurse turns the patient for comfort. With 100 mL of fluid remaining, the nurse has time to perform these tasks. The nurse can inspect the IV dressing last, after going to obtain the next IV fluid bag.)

A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the intravenous (IV) line, and the patient asking to be turned. Which of the following does the nurse perform first?

A) Reconnect the drainage tubing
B) Inspect the condition of the IV dressing
C) Improve the patient's comfort and turn onto her side.
D) Obtain the next IV fluid bag from the medication room

118

B, C

(The skin remaining intact is an appropriate goal for the patient's at-risk diagnosis. A return of normal bowel functioning is also appropriate since it indicates removal of a risk factor.

Turning the patient is an intervention

119

skin condition improving by discharge is a poorly written goal that is not measurable.)

A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of risk for impaired skin integrity. Which of the following goals are appropriate for the patient? (Select all that apply.)

A) Patient will be turned every 2 hours within 24 hours.
B) Patient will have normal bowel function within 72 hours.
C) Patient's skin will remain intact through discharge.
D) Patient's skin condition will improve by discharge.

120

D (Indicates when the patient is expected to respond in the desired manner)

(The time frame indicates when you expect a response to your nursing interventions. Time frames help to organize priorities but do not indicate which problem is most important. Time frames for outcomes are not used to gauge the time it takes to complete interventions, and they are unrelated to a nurse's work schedule.)

Setting a time frame for outcomes of care serves which of the following purposes?

A) Indicates which outcome has priority
B) Indicates the time it takes to complete an intervention
C) Indicates how long a nurse is scheduled to care for a patient
D) Indicates when the patient is expected to respond in the desired manner

121

C (Patient will achieve glucose control.)

(It will take time for the patient who is medically unstable to achieve glucose control. Explaining the relationship of insulin to blood glucose control and self-administering insulin are short term goals and should be met before discharge. Describing steps for preparing insulin in a syringe is not a goal but an outcome statement for the goal that the patient will self-administer insulin.)

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. Which of the following patient care goals are long term?

A) Patient will explain relationship of insulin to blood glucose control.
B) Patient will self-administer insulin.
C) Patient will achieve glucose control.
D) Patient will describe steps for preparing insulin in a syringe.

122

A, C, D

(A goal must be realistic and one that the patient has cognitive and sociocultural potential to reach. The nurse's competency does not influence the patient's goal. However, it may mean that the nurse must consult with a diabetes educator or a more qualified nurse before beginning instruction.)

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. What does the nurse need to determine before setting the goal of "patient will self-administer insulin?" (Select all that apply.)

A) Goal within reach of the patient
B) The nurse's own competency in teaching about insulin
C) The patient's cognitive function
D) Availability of family members to assist

123

D (Patient will report pain acuity less than 4 on a scale of 0 to 10.)

(Answer 4 is measurable because it is the only outcome statement that allows the nurse to obtain an actual measure of the patient's pain. The patient being pain free is a goal

no data

124

the patient having less pain is written vaguely, and the patient taking pain medication every 4 hours is an intervention.)

The nurse writes an expected-outcome statement in measurable terms. An example is:

A) Patient will be pain free.
B) Patient will have less pain.
C) Patient will take pain medication every 4 hours.
D) Patient will report pain acuity less than 4 on a scale of 0 to 10.

125

D (Consult with dietitian on initial foods to offer patient.)

(Providing frequent mouth care and controlling outside stimulation that triggers nausea are independent interventions. Maintaining an IV infusion and administering the rectal suppository are dependent interventions.)

A patient has the nursing diagnosis of nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions?

A) Provide frequent mouth care.
B) Maintain intravenous (IV) infusion at 100 mL/hr.
C) Administer prochlorperazine (Compazine) via rectal suppository.
D) Consult with dietitian on initial foods to offer patient.
E) Control aversive odors or unpleasant visual stimulation that triggers nausea.

126

1B, 2C, 3A

(The patient's oxygenation status is the priority in this situation. The patient's condition creates the risk for activity intolerance, making this an intermediate priority for which the nurse must monitor. Ineffective self-help management is a long-term goal that might be applicable if the patient has physical limitations at the time of discharge.)

A 72-year-old patient has come to the health clinic with symptoms of a productive cough, fever, increased respiratory rate, and shortness of breath. His respiratory distress increases when he walks. He lives alone and did not come to the clinic until his neighbor insisted. He reports not getting his pneumonia vaccine this year. Blood tests show the patient's oxygen saturation to be lower than normal. The physician diagnoses the patient as having pneumonia. Match the priority level with the nursing diagnoses identified for this patient:

Nursing Diagnoses
1. Impaired gas exchange _____
2. Risk for activity intolerance _____
3. Ineffective self-health management _____

Priority Level
a. Long term
b. Short term
c. Intermediate

127

(1) C, (2) D, (3) B, (4) A

An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: risk for fall, impaired physical mobility related to pain, and wandering related to cognitive impairment. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right.

Goals
1. Patient will ambulate independently in 3 days. _____
2. Patient will be injury free for 1 month. _____
3. Patient will be less agitated. _____
4. Patient will achieve pain relief. _____

Outcomes
a. Patient will express fewer nonverbal signs of discomfort.
b. Patient will follow a set care routine.
c. Patient will walk correctly using a walker.
d. Patient will exit a low bed without falling

128

C (During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient.)

(Creating a culture of blame does not support questioning, which is needed for good handoff communication. Talking about the patient's anxiety during handoff is patient centered and thus appropriate, referring to the EHR to review interventions ensures that essential information is included, and administering a pain medication before the report allows the nurse to be organized and uninterrupted during rounds.)

A nurse is preparing for change-of-shift rounds with the nurse who is assuming care for his patients. Which of the following statements or actions by the nurse are characteristics of ineffective handoff communication?

A) This patient is anxious about his pain after surgery

129

you need to review the information I gave him about how to use a patient-controlled analgesia (PCA) pump this evening.
B) The nurse refers to the electronic care plan in the electronic health record (EHR) to review interventions for the patient's care.
C) During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient.
D) The nurse gives her patient a pain medication before report so there is likely to be no interruption during rounding.

no data

130

B, D

(The statement "Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week" is not singular. The statement "Give patient liquid supplements 3 times a day" is an intervention.)

Which of the following outcome statements for the goal, "Patient will achieve a gain of 10 lbs (4.5 kg) in body weight in a month" are worded incorrectly? (Select all that apply.)
A) Patient will eat at least three fourths of each meal by 1 week.
B) Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week.
C) Patient will eat foods with high-calorie content by 1 week.
D) Give patient liquid supplements 3 times a day.

131

B (The patient and family need to be able to independently provide most of the health care.)

(A community-based health care setting such as home health must work with patients and their families to set goals and outcomes that ultimately lead to a plan that allows them to provide the majority of care themselves. Goals of care will not always be more long term

no data

132

goals will be short term and long term, depending on the patient's condition. Mutually setting goals with caregiving family members is true for any health care setting. The statement "The expected outcomes need to address what can be influenced by interventions" is incorrect

no data

133

the outcomes allow you to direct your evaluation of care.)

A nurse from home health is talking with a nurse who works on an acute medical division within a hospital. The home health nurse is making a consultation. Which of the following statements describes the unique difference between a nursing care plan from a hospital versus one for home care?

A) The goals of care will always be more long term.
B) The patient and family need to be able to independently provide most of the health care.
C) The patient's goals need to be mutually set with family members who will care for him or her.
D) The expected outcomes need to address what can be influenced by interventions.

134

C (The patient's wound will reduce in size to less than 4 cm -1 ½ inches- by day 4.)

(An outcome must have terms describing quality, quantity, frequency, length, or weight to allow for precise measurement. The statement "The patient's wound will reduce in size to less than 4 cm - 1 ½ inches - by day 4" identifies a specific wound size, which indicates a degree of healing. The outcome statements concerning the wound appearing normal and having less drainage are vague and not measurable. The statement "The patient's wound will heal without redness or drainage by day 4" has more than one outcome.)

Which outcome allows you to measure a patient's response to care more precisely?

A) The patient's wound will appear normal within 3 days.
B) The patient's wound will have less drainage within 72 hours.
C) The patient's wound will reduce in size to less than 4 cm (1 ½ inches) by day 4.
D) The patient's wound will heal without redness or drainage by day 4.

135

A, C

(The statements "Turn the patient regularly from side to back to side" and "Apply a pressure-relief device to bed" do not provide specific guidelines for the frequency or type of intervention. The other two options identify specific intervention methods.)

A nurse identifies several interventions to resolve the patient's nursing diagnosis of impaired skin integrity. Which of the following are written in error? (Select all that apply.)

A) Turn the patient regularly from side to back to side.
B) Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence.
C) Apply a pressure-relief device to bed.
D) Apply transparent dressing to sacral pressure ulcer.


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