Presentation on theme: "13 Planning."— Presentation transcript: 1 13 Planning Show
2 Directory Classroom
Response System Questions 3 Classroom Response System Questions 4 Question 1
After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor for several hours. Which type of planning will be least useful during the first shift on the orthopedic unit? Initial Ongoing Discharge Strategic
5 Question 1 Answer Initial Ongoing Discharge Strategic 6
Question 1 Rationales The client requires initial planning since he has just arrived on the orthopedic unit for the first time. Of the three types of planning that need to be done at this time, initial is the highest priority since he has just had surgery. The client also requires ongoing planning necessary to determine care appropriate for this shift. Discharge planning starts on admission to ensure adequate client preparation for managing health
needs outside the health agency. Correct. Strategic planning is an ongoing process focused on organizational change rather than on individual clients so it is least useful. 7 Question 2 The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before
determining whether or not this request can be honored, the nurse should consult which of the following? Hospital policies Standardized care plans Orthopedic protocols Standards of care 8
Question 2 Answer Hospital policies Standardized care plans 9 Question 2 Rationales Correct. Policy and procedure documents provide data about how certain situations are handled. Note: Even hospital policies are not absolute. Each
situation must be analyzed and responded to individually. Standardized care plans are written for groups of clients with similar medical or nursing diagnoses. They generally do not address questions such as hospital routines and nonmedical client needs. Orthopedic protocols would address elements specifically associated with the surgery. Standards of care are written for groups of clients with similar medical or nursing diagnoses. They usually do not
address hospital routine or nonmedical client needs. 10 Question 3 The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when aroused. The client’s pain is 2 on a scale of 0 to 10; vital signs are within preoperative range; extremities are warm with good pulses but very dry skin. The
client declines oral fluids due to nausea and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which element would likely be high priority for the current care plan? Pain Nausea Constipation Potential for wound infection
11 Question 3 Answer Pain Nausea Constipation
12 Question 3 Rationales The client’s pain level is not extreme
considering his recent surgery, and pain intervention can be assumed to be effective. Correct. A more detailed assessment data and consultation with the client would be needed to confirm the priority. Postoperative nausea that inhibits oral intake has the greatest likelihood of leading to complications and requires nursing intervention now. Although the constipation is probably bordering abnormal, nursing intervention would most likely begin with oral treatment, which
is not possible due to the nausea. Wound infection can occur but there are no data to indicate that this requires a change in the current plan. 13 Question 4 The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and a surgical incision. Which of the following
represents a properly stated outcome/goal? The client will: Turn in bed q2h. Report the importance of applying lotion to skin daily. Have healthy intact skin during hospitalization. Use a pressure-reducing mattress. 14 Question 4 Answer Turn
in bed q2h. 15 Question 4 Rationales Turning in bed is an intervention that may result in achieving the goal, but the goal or
outcome should state the opposite of the nursing diagnosis stem. The goal or outcome should state the opposite of the nursing diagnosis stem. Applying lotion is an intervention that may help in achieving the goal. Correct. The goal or outcome should state the opposite of the nursing diagnosis stem; healthy intact skin is the opposite of impaired skin integrity. The goal or outcome should state the opposite of the nursing diagnosis stem. Using a
pressure-reducing mattress is an intervention that may result in achieving the goal. 16 Question 5 The care plan includes a nursing intervention “4/2/11 Measure client’s fluid intake and output. F. Jenkins, RN.” What element of a proper nursing intervention has been omitted? Action verb Content
Time None 17 Question 5 Answer Action verb Content Time None
18 Question 5 Rationales Incorrect. In the sentence, “measure” is an action verb. Incorrect. Content is not missing. Correct.
Although there may be standard policies or routines for measuring intake and output, the nursing intervention should specify if this is to be done “routinely” or at specific intervals (e.g., q4h). However, critical thinking indicates that the intake and output should be monitored more frequently than ordered if assessment reveals abnormal findings. Incorrect. A time element was missing.
19 Lecture Note Presentation 20 Learning
Outcomes Identify activities that occur in the planning process. Compare and contrast initial planning, ongoing planning, and discharge planning. Explain how standards of care and preprinted care plans can be individualized and used in creating a comprehensive nursing care plan. 21
Learning Outcomes (cont'd) 22 Learning
Outcomes (cont'd) 23
Learning Outcomes (cont'd)
24 Planning Deliberate, systematic, problem-solving phase of nursing process Decide on nursing interventions Nurse responsible, but
input from client essential 25 Figure Planning. The third phase of the nursing process, in which the nurse and client develop client goals/desired outcomes and nursing interventions to prevent, reduce, or alleviate the client’s health problems. 25
26 Planning (cont’d) Begins with first client contact
27 Initial Planning Develops initial comprehensive plan of care 28 Ongoing Planning Done by all nurses who work with the client
29 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 30 Developing Nursing Care Plans 31 Developing Nursing Care Plans (cont'd) 32 Standardized Approaches to Planning
33 Standards of Care Describe nursing actions for clients with similar medical conditions
Describe achievable rather than ideal nursing care Define interventions for which nurses are accountable Usually agency records that may be referred to in client’s care plan 34 Standards of Care (cont'd) 35 Standardized Care Plans
36 Protocols Indicate actions commonly required for a particular groups of clients May include both primary care provider’s orders and nursing interventions Example: protocol for admitting a
client to the intensive care unit 37 Policies and Procedures
38 Standing Order Written document
39 Individualization of Standardized Care Plans 40 Formats for Nursing Care Plans 41 Figure 13-5 A sample pathophysiology concept map.
42 Guidelines for Writing Nursing Care Plans 43 Guidelines for Writing Nursing Care Plans (cont'd) 44 The Planning Process Consists of following activities: 45 Setting Priorities
Establishing a preferential sequence for addressing nursing diagnoses and interventions High priority (life-threatening) Medium priority (health-threatening) Low priority (developmental needs) 46 Factors to Consider When Setting
Priorities 47 Goals/Desired Outcomes 48 Table 13-2 Deriving Desired Outcomes from Nursing Diagnoses
49 Nursing Outcomes Classification (NOC) 50 Nursing Outcomes Classification (NOC) (cont’d) 51 Purpose of Desired Goals/ Outcomes 52 Relationship of Desired Goals/
Outcomes to Nursing Diagnosis
53 Components of Goal/Desired Outcome Statements
54 Guidelines for Writing Goals/Desired Outcomes 55 Nursing Interventions and Activities 56 Types of Nursing Interventions 57 Types of Nursing Interventions (cont'd) 58 Criteria for Choosing Appropriate Interventions 59 Criteria for Choosing Appropriate Interventions
(cont'd) 60 Writing Individualized Nursing Interventions 61 Relationship of Nursing Interventions to
Problem Status 62 Delegating Implementation 63 Nursing Interventions Classification (NIC) 64 Levels of NIC Consists of three levels: Level 1 - domains
65 NIC Interventions More than 542 interventions developed 66 Concept Map See Concept Map, Planning What does the nurse perform first in initiating the implementation phase of the nursing process?When initiating the implementation phase of the nursing process, the nurse performs which of the following phases first? Rationale: The first step of implementing is reassessing the client to determine that the activity is still indicated and safe.
Which of the following is the primary purpose of the evaluating phase of the care planning process?The purpose of evaluation is to determine the effectiveness of nursing care. The other options are not true statements. During evaluation, you do not simply determine whether nursing interventions were completed.
Which of the following is an example of an expected outcome statement in measurable terms?The nurse writes an expected-outcome statement in measurable terms. An example is: A. Patient will be pain free.
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