CH 18 & 19 & 20 planning, implementation, and evaluation

Question 1

ADPIE

Answer 1

Assess
Diagnose
Planning
Implementation
Evaluation

Question 2

What is included in planning?

Answer 2

setting priorities

identifying patient-centered goals and expected outcomes

prescribing individualized nursing interventions

Question 3

What are the classifications of priorities when planning?

Answer 3

High—Emergent

Intermediate

Low—Affect patients’ future well-being

Question 4

High priority

Answer 4

if untreated result in harm to the patient -

things like safety, ABCs / basic human needs

Question 5

Intermediate priority

Answer 5

non emergent and non life threatening needs

Question 6

Low priority

Answer 6

deals with patients future well-being

Question 7

what is Maslows hierarchy of needs? Bottom to top

Answer 7

• Physiological needs
• Safety and security
• love and belonging
• self esteem
• self actualization

Question 8

Goals and outcomes must be…

Answer 8

relevant to patient needs, specific, singular, observable, measurable, and time limited

Question 9

patient centered goal

Answer 9

a specific and measurable behavior or response that reflects a patients highest possible level of wellness and independence in function

Question 10

short term goal

Answer 10

an objective behavior or response expected within hours to a week

Question 11

long term goal

Answer 11

an objective behavior or response expected within days weeks or months

Question 12

SMART

Answer 12

Singular
Measureable(observable)
Attainable
Realistic
Time limited

Question 13

nurse initiated intervention

Answer 13

independent

Question 14

physician initiated intervention

Answer 14

dependent - requires order from HCP

Question 15

collaborative

Answer 15

interdependent - require multiple health care professionals combined knowledge and skill

Question 16

Clarifying an order

Answer 16

determine whether the therapy is appropriate for the patient and clarify with the physician if needed

Question 17

Hand-off reporting

Answer 17

important patient information that ensures continuity of care

Question 18

Critical pathways

Answer 18

are patient care plans that provide the multidisciplinary health care team with activities and tasks to be put into practice sequentially

Question 19

Consultation

Answer 19

a process by which you seek the expertise of a specialist such as your nursing instructor, a physician, or a clinical nurse educator to identify ways to handle problems in patient management or in planning and implementation of therapies.

Question 20

nursing intervention

Answer 20

any treatment based on clinical judgement and knowledge that a nurse performs to enhance patient outcomes

Question 21

5 rights of delegation

Answer 21

Right task
Right circumstance
Right person
Right direction/communication
Right supervision/evaluation

Question 22

Criterion-based standards for evaluation

Answer 22

physiological, emotional, and behavioral responses that are both
patient goals and expected outcomes

Question 23

Discontinuing a care plan steps

Answer 23

Has the goal been met?

Does the patient agree?

Document the discontinued plan.

Question 24

What are the steps to modifying a care plan?

Answer 24

Reassessment

Redefining diagnoses

Goals and expected outcomes

Question 25

What are the two stages of assessment?

Answer 25

Collection and verification

interpretation and validation

Question 26

What are the 4 areas of critical thinking?

Answer 26

Knowledge base

Experience

Attitudes

Standards

Question 27

What are the 6 sources of data?

Answer 27

patient
family and sig others
health care team
med records
scientific lit
nurse's experience

Question 28

What are the two types of comprehensive approaches?

Answer 28

Structured data base history

problem oriented

Question 29

Back channeling?

Answer 29

“uh huh” or “go on…”

Question 30

3 types of nursing DX?

Answer 30

actual or problem focused

Wellness or health promotion

risk

Question 31

What does PES stand for?

Answer 31

Problem
Etiology
Symptoms