Nursing Process Part 2: Outcome Identification, Planning, Implementation, and Evaluation

Comprehensive flashcards covering the planning, implementation, and evaluation phases of the nursing process, including Maslow’s hierarchy, outcome writing, and delegation principles.

Focus of Nursing Outcome Identification and Planning

To design a patient-centered plan of care, establish priorities, identify and document expected patient outcomes, select appropriate evidence-based nursing interventions, and communicate the plan.

Initial Planning

Planning that occurs on admission.

Discharge Planning

Planning that starts on admission.

Maslow’s Hierarchy of Human Needs

A framework for establishing priorities consisting of physiologic needs, safety needs, love and belonging needs, self-esteem needs, and self-actualization needs.

SMART Outcomes

An acronym indicating that goals should be specific, measurable, attainable, realistic, and timebound.

Cognitive Outcomes

Outcomes that describe increases in patient knowledge.

Psychomotor Outcomes

Outcomes that describe the pt’s achievement of new skills.

Affective Outcomes

Outcomes that describe changes in pt’s values, beliefs, and attitudes.

Components of Patient-Centered Measurable Outcomes

Must include a subject, verb, conditions, performance criteria, and target time.

Plan of Nursing Care

A written guide that directs the nurses to meet their pt’s health goals; types include nursing diagnoses, computerized, clinical pathways, concept maps, and student documentation.

Nursing Intervention

Any treatment based upon clinical judgment and knowledge that a nurse performs to enhance pt outcomes.

Nurse-initiated interventions (independent)

Interventions that are nurse prescribed.

Protocols

Written plans that detail nursing activities.

Standing orders

Orders that allow a nurse to initiate actions that normally require a physician’s order.

Noncompliance factors

Lack of family support, lack of understanding, low value attached to outcomes, adverse physical/emotional effects of treatment, financial issues, and access.

Delegation

The transfer of responsibility for the performance of an activity to another individual while retaining the accountability for the outcome.

UAP

Unlicensed assistive personnel.

Nursing Evaluation

Phase where the nurse and the pt measure together how well the pt has achieved the outcomes identified in the plan of care.

Outcome achievement actions

If an outcome is achieved, terminate the plan; if an outcome is not achieved, modify the plan.

Physiologic Outcomes

Evaluative data used to determine physical changes in the patient.

Concept Map Components

Visual representation including Pathophysiology, Diagnostic Tests, Clinical Manifestations, Nursing Diagnosis, Medical Diagnosis, Pt Data/Risk Factors, Nursing Interventions, Medicine, Medical Rx, and Patient Education.