Chapter 13: Outcome Identification & Planning

A nurse is planning care for a male adolescent patient who is admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process?

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning?

When helping a patient turn in bed, the nurse notices that his heels are reduced and plans to place him on precautions for skin breakdown. This is an example of what type of planning?

A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: List the problems in order of highest priority to lowest. 1. [blank_start]Ineffective Airway Clearance[blank_end] 2. [blank_start]Impaired Social Interaction[blank_end] 3. [blank_start]Disturbed Body Image[blank_end] 4. [blank_start]Spiritual Distress[blank_end]

A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care?

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. An example of an affective outcome for this patient is

A nurse is preparing a clinical outcome for a 32-year-old female runner who is recovering from a stroke that caused right-sided paresis. An example of this type of outcome is:

A nurse is caring for an elderly male patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written?

A nurse is collecting more patient data to confirm a diagnosis of emphysema for a 68 year old male patient. What type of diagnosis does this intervention seek to confirm?

A nurse is caring for a patient who is diagnosed with congestive heart failure. Which statement below is not an example of a well-stated nursing intervention?

You should first meet the needs that the patient thinks are most important, as long as this order does not interfere w/other vital therapies.

For each nursing diagnosis at least one outcome should be written, that if achieved, demonstrates a direct resolution of the problem.

to be measurable, outcomes should have the following: subject, verb, conditions (optional), performance criteria, target time During the next 24 hr period, the patient's fluid intake will total at least 2,000 mL subject: [blank_start]the patient's fluid intake[blank_end] verb: [blank_start]will total[blank_end] performance criteria: [blank_start]2,000 mL[blank_end] target time: [blank_start]during the next 24hr[blank_end]

to be measurable, outcomes should have the following: 1. [blank_start]subject[blank_end]: the patient or some part of the patient 2. [blank_start]verb[blank_end]: indicates the action the patient will perform (i.e., define, prepare, verbalize, demonstrate, etc.) 3. [blank_start]conditions[blank_end]: specifies the particular circumstances in or by which the outcome is to be achieved (optional) 4. [blank_start]performance[blank_end] [blank_start]criteria[blank_end]: describe in observable, measurable terms the expected patient behavior or other manisfestation 5. [blank_start]target[blank_end] [blank_start]time[blank_end]: specifies when the patient is expected to be able to achieve the outcome. may be a realistic actual date or statement indicating time (i.e. before discharge, whenever observed, etc.)

But whereas the [blank_start]problem[blank_end] [blank_start]statement[blank_end] of the diagnosis suggests the patient goals, it is the cause of the problem that suggest the [blank_start]nursing[blank_end] [blank_start]interventions[blank_end].

Structure Care Methodologies [blank_start]Algorithm[blank_end]: 1. Binary decision trees that guide step wise assessment and intervention 2. Useful in management of high-risk subgroups w/in the cohort, may be layered on top of a pathway to control care practices that are used to manage a specific problem 3. Intense specificity, no provider flexibility 4. May use analytical research methods to ensure cause/effect [blank_start]Clinical Pathway[blank_end] 1. Represents a sequential, interdisciplinary, minimal practice standard for a specific patient population 2. Provides flexibility to alter care to meet individualized patient needs 3. Ability to measure cause/effect relationship between pathway and patient outcomes [blank_start]Guideline[blank_end] 1. Broad, research based practice recommendations 2. May or may not have been tested in clinical practice 3. No mechanism for ensuring practice implementation [blank_start]Order Set[blank_end] 1. Preprinted provider orders used to expedite the order process after a practice standard has been validated through analytical research 2. Compliments and increases compliance w/existing practice standards 3. Can be used to represent the algorithm or protocol in order format [blank_start]Protocol[blank_end] 1. Prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of patients w/the cohort 2. Multifaceted; may be used to drive practice for more than one discipline 3. Broader specificity than an algorithm; allows for minimal provider flexibility by way of treatment option 4. May be layered on top of a pathway

A nurse is giving postoperative care to a client after knee arthroplasty. Which of the following is a possible short term goal for this client?

The nursing student asks the nurse about nurse-initiated and physician-initiated nursing interventions. Which of the following is a nurse initiated nursing intervention?

Which of the following are verbs that are helpful in writing measurable outcomes

Which of the following outcomes is sufficiently measurable?

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. What type of tool is the nurse using?

Which of the following reflects outcome identification?

Which one of the following is categorized as a psychomotor outcome?

Which statement correctly describes a nurse-initiated intervention?

although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?

What is true of nursing responsibilities with regards to a physician initiated intervention (physician's order)?

A client's diagnoses of breast cancer necesitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on her ADLs. When should discharge planning to address ADLs begin for this client?

When the nurse notices a client is in pain and needs to learn to walk on crutches, which outcome identification is the priority?

A nurse writes down the following outcome for a depressed client "By 6/9/12 the client will state 3 positive benefits of receiving counseling." This is an example of which of the following types of outcome?

When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "Client will know how to self-administer his prescribed bronchodilators using a nebulizer by 9/9/15" Why is this outcome inadequate?

The nurse recognizes that identifying outcomes/goals must include which of the following?

Patient education in the care of a male patient with emphysema has focused on smoking cessation. As a result, nurses have prioritized the following outcome in his plan of care "By 1/12/2011, patient will state that he no longer smokes" This outcome contains which of the following components of a measurable outcome?

Which of the following is a correctly written nursing intervention?

An older adult female client has been admitted to the hospital for treatment of exacerbation of chronic obstructive pulmonary disease. Which of the following statement constitutes a long-term outcome?

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning?