SG 9

Standardize Care Plan

A formal plan that specifies the nursing care for groups of clients with common needs. 

planning

Deliberate, systematic phase of the nursing process involving decision making and problem solving. 

discharge planning

The process of anticipating and planning for needs after discharge.

protocols

Are predeveloped to indicate the actions commonly required for a particular group pf clients.  

standing order

Written document about policies, rules, regulations, or orders regarding client care.  

individualized care plan

Tailored to meet the unique needs of a specific client, and needs that are not addressed by the standardized plan.  

policies and procedures

Developed to govern the handling of frequently occurring situations.  

collaborative/multidisciplinary care plan

Standardized plan that outlines the care required for clients with common, predictable – usually medical – conditions.  

raionale

Evidence-based principle given as the reason for selecting a particular nursing intervention.  

goals

Broad statements about the client’s status

desired outcomes

The more specific, observable criteria used to evaluate whether the goals have been met.  

priority setting

The process of establishing a preferential sequence for addressing nursing diagnoses and interventions.  

dependent interventions

Activities carried out under the orders or supervision of a licensed physician or other health care provider authorized to write orders to nurses.  

independent interventions

Activities that nurses are licensed to initiate on the basis of their knowledge and skills.  

collaborative intervebtions

Actions the nurse carries out in collaboration with other health team members.  

clinical judgement

Nursing intervention is “any treatment, based upon ____________________ and knowledge, that a nurse performs to enhance patient/client outcomes.  

client care plan

The end product of the planning phase is a ______________________.

client & support persons

Although planning is basically the nurse’s responsibility, input from the ________________________  is essential if a plan is to be effective

encourages the client to participate

Nurses do not plan for the client, but __________________________ actively to the extent

caregivers are the ones who implement

In a home setting, the client’s support people and ___________________________________ the plan of care; thus, its effectiveness depends largely on them.  

when the client is discharged form the health care agency

Planning begins with the first client contact and continues until the nurse-client relationship ends, usually ______________________________________.  

multidisciplinary

All planning is________ and includes the client and family to the fullest extent possible in every step.  

• initial planning

• ongoing planning

• discharge planning

Types of Planning

initial comprehensive plan of care

The nurse who performs the admission assessment usually develops the _________________________.

client’s body language

The nurse who performs the admission assessment has the benefit of seeing the ______________________.

planning

_______________________________should be initiated as soon as possible after the initial assessment.  

evaluate the client’s responses to care

As nurses obtain new information and ____________________________________ , they can individualize the initial care plan further.  

ongoing planning

________________________ also occurs at the beginning of a shift as the nurse plans the care to be given that day.

• to determine whenever the client’s health status has changed

• to set priorities for the client’s care during the shift

• to decide which problems to focus on during the shift

• to coordinate the nurse’s activities so that more than one problem can be addressed in each client contact

Using ongoing assessment data, the nurse carries out daily planning for the following purposes

discharge planning

______________________________, is a crucial part of a comprehensive health care plan and should be addressed in each client’s care plan.

needing care

People are sometimes discharged from the hospital still _________________________. 

ongoing assessment

Effective discharge planning begins at first client contact and involves comprehensive and ______________________ to obtain information about the client’s ongoing needs.

plan of care

The end product of the planning phase of the nursing process is a formal or informal _______________.  

nurse’s mind

An informal nursing care plan is a strategy for action that exists in the ___________________________.  

written or computerized guide

40. A formal nursing care plan is a _____________________________ that organizes information about the client’s care.  

 

common needs

Standardized care plan is a formal plan that specifies the nursing care for groups of clients with ________________________.  

same outcomes

42. It is important for all care givers to work toward the __________________, and if available use approaches shown to be effective with a particular client.  

 

clients; nursing diagnoses

When nurses use the _________________________________ to develop goals and nursing interventions, the result is holistic, individualized plan of care that will meet the client’s unique needs.

actions nurses must take

Care plans include the _______________________________ to address the client’s nursing diagnoses and produce the desired outcomes.  

evaluations of goal

The nurse begins the plan when the client is admitted to the agency and updates it throughout the client’s stay in response to changes in the client’s condition and _______________________________ achievement.

individualized care

Decide which of the client’s problems need ___________________________________ and which problems can be addressed by standardized plans and routine care.

nursing attention

Write individualized desired outcomes and nursing interventions for client problems that requires ____________________________________  beyond preplanned, routine care.  

different documents

The complete plan of care for a client is made up of several ___________________________________. 

integrates dependent & independent nursing function

A complete plan of care _______________________________________________________________                 into a meaningful whole and provides a central source of client information.

criteria are met

Ensure that minimally acceptable ___________________. 

nurses’ time

Promote efficient use of ____________________ by removing the need to author common activities that are done repeatedly for many of the clients on a nursing unit.

achievable

Standards of care describe nursing actions for clients with similar medical conditions rather than individuals, and they describe __________________rather then ideal nursing care.

nurses are held accountable for

Standards of care define the interventions for which ______________________________; they do not contain medical interventions.

agency records

Standards of care are usually____________________________ and not part of the client’s care plan, but they may be referred to in the plan.

not be organized

55. Standards of care may or may ______________________________ according to problems or nursing diagnoses.  

 

what care the client can expect

Standards of care are written from the perspective of ___________

predeveloped guides

Standardized care plans are ___________________________________ for the nursing care of a client who has a need that arises frequently in the agency. 

certain circumstances

Standing orders give nurses the authority to carry out specific actions under __________________________, often when a primary care provider is not immediately available.

sign the plan

Date and _______________________.

headings

Use category ____________________.  

symbols

Use standardized/approved medical or English __________________ and key words rather then complete sentences

speific

be________

information

Refer to procedure books or other sources of _____________________ rather than including all the steps on a written plan.  

client’s choice

Tailor the plan to the unique characteristics of the client by ensuring that the __________________, such as preferences about the times of care and the methods used.  

incorporates preventive

Ensure that the nursing plan ____________________________________ and health maintenance aspects as well as restorative ones.  

ongoing assessment

Ensure that the plan contains _________________________________of the client.  

coordination activities

Include collaborative  and ____________________________________ in the plan. 

home care needs

Include plans for the client’s discharge and __________________________________.  

nurse’s signature

The _______________________________________demonstrates accountability to the client and to the nursing profession, since the effectiveness of nursing actions can be evaluated.  

specific about expected timing

Because nurses are now working shifts of different lengths, with some working 12 -hour shifts and 8 hours shift, it is even more important to be____________________________________ of an intervention.  

• setting priorities

• establishing clients goals/desired outcomes

• selecting nursing interventions and activities

• writing individualized nursing interventions on care plans

In the process of developing client care plans, the nurse engages in the following activities: (#s 72 – ________________________________________________ 

________________________________________________ 

________________________________________________ 

________________________________________________. 

priority

Instead of ran-ordering diagnoses, nurses can group them as having high, medium, or low ___________.

high priority

Life threatening problems, such as impaired respiratory or cardiac function, are designated as __________________.

middle priority

Health-threatening problems, such as acute illness and decreased coping ability, are assigned ________________________.  

minimal nursing support

A low-priority problem is one that arises from normal developmental needs or that requires only _______________________________________ .  

airway clearance

Ineffective __________________________ and Impaired Gas Exchange would take priority over nursing diagnoses such as Anxiety or Ineffective Coping.

resolve

It is not necessary to _______________ all high-priority  diagnoses before addressing others. 

time

The nurse often deals with more than one diagnosis at a _________________.  

priorities change

___________________________  as the client’s responses, problems, and therapies change.  

• clients health values and beliefs

• clients priorities

• resources available to the nurse and client

• urgency of the health problem

• medical treatment plan

Variety of factors when assessing priorities: (#s 84 – 88) 

________________________________________ 

________________________________________  

________________________________________ 

________________________________________ 

________________________________________ 

 

cooperation

Involving the client in prioritizing and care planning enhances ____________________________.  

setting of priority

Client resources, such as finances or coping ability, may also influence the ______________________.   

high priority

Regardless of the framework used, life-threatening situations require that the nurse assign them a ___________________________.  

negative or destructive effect

Situations that affect the integrity of the client, that is, those that could have a _____________________  on the client, also have high priority.  

must be congruent

The priorities for treating health problems __________________________________ with treatment by other health professionals.  

 set goals for each nursing diagnosis

After establishing priorities, the nurse and client ________________________________________. 

desired outcomes

When goals are stated broadly, the care plan must include both goals and ________________________.  

starting point for planning

Writing the broad, general goal first may help students to think of the specific outcomes that are needed, but the broad goal is just a ___________________________________.  

evaluate client progress

It is the specific, observable outcomes that must be written on the care plan and used to ____________. 

conceptual

The NOC outcomes are broadly stated and _____________________________.  

identifying indicators

To be measured, an outcome must be made more specific by _______________________________ that apply to a particular client.  

assess the effectiveness

It is important to note the nursing-sensitive outcome indicators _________________________of nursing interventions

direction for planning

Provide ______________________________ nursing interventions

criteria for evaluating

Serve as ________________________________ client progress.

resolved

Enable the client and nurse to determine when the problem has been _____________________.  

sense of achievement

Help motivate the client and nurse by providing a ________________________________.

client’s immediate needs

In acute care setting, much of the nurse’s time is spent on the _________________________, so most goals are short term.  

outcomes

_________________________are often set for clients who live at home and have chronic health problems and for clients in nursing homes, extended care facilities, and rehabilitation centers.  

diagnostic label

Goals and outcomes are derived from the client’s nursing diagnoses – primarily from the ________________________

unhealthy response

The diagnostic label contains the ______________________________; it states what should change.  

resolution of the problem

For every nursing diagnosis, the nurse must write the desired outcome(s), that when achieved, directly demonstrates _________________________________.  

• subject

• verb

• conditions or modifiers

• criterion of desired performance

Components of Goal / Desired Outcome Statements: (#s 110 – 113) 

____________________________________ 

____________________________________ 

____________________________________ 

____________________________________  

client’s response

Write goals and outcomes in terms of ______________________________, not nursing activities.  

need to accomplish

The verbs enable, facilitate, allow, let, permit.. indicates what the nurse ________________________, not what the client will do.  

 

realistic for the client’s capabilities

Be sure that desired outcomes are  _________________________________________, limitations, and designated time span, if indicated.