Chapter 13: Outcome Identification & Planning: Vocabulary

Question	Answer
During outcome identification/planning the nurse works in partnership w/the patient/family to	1. Establish priorities 2. Identify/write expected patient outcomes 3. Select evidence-based nursing interventions 4. Communicate the plan of nursing
patient outcome	an expected conclusion to a patient health problem/expectations
expected outcomes	refers to the measurable criteria used to evaluate the extent to which a goal has been met
primary purpose of the outcome identification/planning	to design a plan of care w/& for the patient, that once implemented results in prevention, reduction, or resolution of patient health problem
initial planning	performed by nurse w/admission history/physical assessment. comprehensive plan addresses each problem listed in the prioritized nursing diagnoses
standardized care plans	prepared plans of care that identify nusing diagnoses, outcomes and related interventions common to a specific population or health problem. can be individualized.
ongoing planning	carried out by nurses who interacts w/the patient. chief purpose is to keep plan up to date.
discharge planning	best carried out by nurse who has worked most closely w/patient/family. in acute care, discharge planning begins when the patient is admitted for treatment
high priority diagnoses	pose the greatest threat to the patient
long-term outcomes	require usually more than a week to be achieved
Outcomes are categorized by the type of change needed by a patient. Name the types.	1. Cognitive outcome 2. Psychomotor outcome 3. Affective outcome 4. Clinical outcome 5. Functional outcome 6. Quality of life outcome
cognitive outcome	describe increases in patient knowledge or intellectual behavior: "W/in 1 day after teaching, the patient will list 3 benefits of continuing to apply moist compresses to leg ulcer after discharge"
psychomotor outcomes	describe the patient's achievement of new skills: "By 6/12/15, the patient will correclty demonstrate application of wet-to-dry dressing of leg ulcer"
affective outcomes	describe changes in patient values, beliefs, and attitudes. critical to the resolution of a complext patient problem: "By 6/12/15 the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer"
clinical outcomes	describe the expected status of health issues at certain points in time, after treatment is complete. address whether the problems are resolved or to what degree they were improved
functional outcomes	describe the person's ability to function in relation to the desired usual activities
quality of life outcomes	focus on key factors that affect someone's ability to enjoy life and achieve personal goals
to be measurable, outcomes should have the following	subject, verb, conditions (optional), performance criteria, target time
goasl/outcomes should be SMART	s - specific m - measurable a - attainable r - realistic t - time bound
for actual diagnoses, interventions seek to	1. reduce/eliminate contributing factors of the diagnosis 2. promote higher-level wellness 3. monitor/evaluate status
for risk diagnoses interventions seek to	1. reduce or eliminate risk factors 2. prevent the problem 3. monitor and elevate status
for possible diagnoses interventions seek to	collect additional data to rule out or confirm the diagnosis
for collaborative problems, interventions seek to	1. monitor for changes in status 2. manage changes in status w/nurse prescribed & physician-prescribed interventions 3. evaluate response
6 factors to consider when choosing an intervention	1. desired patient outcomes 2. characteristics of the nursing diagnosis 3. research base for the intervention 4. feasibility for doing the intervention 5. acceptability to the patient 6. capability of the nurse
each nursing intervention should include	1. date 2. verb (action to be performed) 3. subject (who is to do it) 4. descriptive phrase (how, when, where, how often, how long, or how much)
comprehensive nursing interventions specify	1. what observations (assessments) need to be made and how often 2. what interventions need to be done and when they must be done 3. what teaching, counseling and advocacy needs patients and families have
physican-initiated intervention	initiated by a physician in response to a medical diagnosis but carried out by a nurse in response to a doctor's order. both physician/nurse legally responsible.
collaborative interventions	treatments initiated by other providers
Evaluative statements include	a statement about achievement of the desired outcome (met, partially met, not met) and list actual patient behavior as evidence.
plan of nursing care	patient care plan. written guide that directs the efforts of the nursing team working w/patients to meet their health goals
3 types of nursing care	1. nursing care related to basic human needs 2. nursing care related to nursing diagnoses 3. nursing care related to the medical/interdisciplinary plan of care
nursing care related to basic human needs	communicates the data about the patient's usual health habits and patterns (i.e. if a toddler is toilet trained, what words they use, etc.)
nursing care related to nursing diagnoses	contains outcomes/interventions for every nursing diagnosis as well as patient responses. heart of nursing care plan
nursing care related to the medical/interdisciplinary plan of care	current medical records for diagnostic studies and treatment related to nursing care
formats for plans of care	1. computerized plans of nursing care 2. concept map plans of care 3. changes of shift reports 4. multidisciplinary (collaborative) plans of care

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Chapter 13: Outcome Identification & Planning: Vocabulary

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	Created by Alexandra Bozan over 6 years ago