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201 A TEST #3

DEFINE AND DISCUSS THE PURPOSE OF OUTCOME IDENTIFICATION

Outcome identification- For each nursing diagnosis, patient-centered goals are identified

To identify goals: - What will you see, hear, palpate or observe that if the problem were

resolved or reduced?prevented?Nursing diagnosis describes actual or potential problem/Desired goal is healthy alternative

SMART OUTCOME SpecificMeasurableAttainableRealisticTime-targeted

DESCRIBE HOW GOALS ARE ESTABLISHEDGoals should:

- Resolve or reduce the problem- Be attainable & realistic in time frame specified - Represent a greater level ofachievement for client- Not conflict with MD orders Establish goals mutually with patient if possible/Describes behavior that:Nurse can measure objectively ORPatient can measure subjectively

DIFFERENTIATE BTWN LTG AND STGLTG-Reflects optimal resolution or reduction of problem - Expected to be achieved over longer period of

time (days, weeks or months)STG-- Expected to be achieved in relatively shorter time period (hour, day, week) - Stepping stone on the way to achievinglong-term goals

IDENTIFY THE CHARACTERISTICS OF AN ACCURATELY FORMULATED GOAL STATEMENTDiagnostic Statement: Impaired skin integrity r/t impaired sensation and circulation aebstage II pressure ulcer on coccyx STG: (Patient will) Describe 3 measures that she can do to prevent pressure ulcers during my shift LTG: (Patients) Pressure ulcer will heal within two months

DESCRIBE THE COMPONENTS OF THE NURSING PLAN OF CARE Nursing Process Steps-

Assessment: collect data /Diagnosis: analyze data to identify problems /Outcome Identification: formulate goals

Planning: selecting nursing interventions /Implementation: perform interventions

Evaluation: determining patients response to interventions & degree of goal achievement

WEEK 8DEFINE AND DISCUSS THE PURPOSE OF IMPLEMENTATION AND EVALUATION

Implementation

Action phase of nursing processRN sets Interdisciplinary plan in motion-Communicates plan to health care team -Supervises/delegates responsibility asindicated-Team reports significant findings back to RN

Implementation Skills

CognitiveInterpersonalPsychomotorReassess to make sure needs unchangedDetermine need for assistanceExplain to patient:-What is to be done & why (rationale)-What to expect & what expected to doIf it isnt documented:-You didnt do it (legal)-Patient may receive it twice (safety)

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EVALUATION-Determine effectiveness of nursing careAnalyze success of goals & interventionsIncorporates input from team and patientCyclical - leads back to assessmentEVAL. ACTIVITIES:Collect dataExamine response to interventions & comparewith goalsRecord goal attainmentRevise/modify care plan as indicated

Describe the clinical skills needed to implement the plan of care

Cognitive Interpersonal Psychomotor Action phase of nursing process RN sets Interdisciplinary plan in motion. Communicates plan to health care team- Supervises/delegates responsibility as indicated

Explain methods for revising or modifying the plan of care

Determine effectiveness of nursing care Analyze success of goals & interventions Incorporates input from teamand patient Cyclical - leads back to assessment Collect data Examine response to interventions & compare withgoals Record goal attainment Reassess to make sure needs unchanged

Determine need for assistance

Describe the activitys carried out during the evaluation stage of the nursing process

EVALUATION-Determine effectiveness of nursing careAnalyze success of goals & interventionsIncorporates input from team and patientCyclical - leads back to assessmentEVAL. ACTIVITIES:Collect dataExamine response to interventions & comparewith goalsRecord goal attainmentRevise/modify care plan as indicated

Identify and prioritize the nursing diagnoses and formulate a nursing care plan for a client situation

1. Use technique of reflection to identify patientsfeelings regarding her health. R: Anxiety delays sleep onset. Therapeutic

communication allows a patient to work through feelings and problems. (Craven & Hirnle,

2009) 2. Teach client to avoid drinking caffeine-containingbeverages after noon & alcoholic

beverages just before bedtime. R: Caffeine is a CNS stimulant that lengthens sleeplatency

and increases nighttime wakening. Alcoholinduces drowsiness but suppresses REM sleep &

increases wakening (Craven & Hirnle, 2009) 3. Assess clients subjective report of the quality

ofher sleep each morning. R: Single most important criterion for adequacy of sleep & rest is

the clients statement (Craven & Hirnle, 2009) 4. Cluster nursing activities to provide for

periods ofuninterrupted sleep time of at least 2 hours whenever possible. R: Sleep cycles

average 90 min. Sleep latency of 20 -30 min means that it takes about 2 hours toexperience a

full sleep cycle (Craven & Hirnle, 2009) STG: Verbalize 2 factors that inhibit sleep during myshift LTG: Will report that she is sleeping soundly at night by

10/30

Identify appropriate client rationale to support identified nursing interventions

1. State the rationale for each interventions. Rationale states the principle upon which theintervention is based-why you, as a nurse, performed the intervention and why it will

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assist in meeting the identified objectives and resolving the stated nursing diagnosis. It isa cause and effect statement.

2. Each rationale is a shot statement of cause and effect (i.e., this intervention help because).3. The rationale should integrate pathophysiological explanations

Define the three phase of post operative care

-Preoperative: begins with decision to performsurgery & ends when client in OR- Intraoperative: begins with entry into OR & endswhen client is in recovery room -Postoperative Recovery: Immediate: Postanesthesia care unit(PACU)Ongoing: begins with return to clinical unit (M/S, ICU); ends at discharge from facility

identify the health factors that affect patients preoperatively

health history comorbidies , medications lifestyle, age

identify legal and eithical considerations re;aetd to obtaining informed consesnt

MD responsible for obtaining informed consent

Conditions of informed consent- Adequate disclosure of risks & benefits- Patient has clear understanding & comprehension- Consent given voluntarily Pt must sign informed consent in front of witness RN witnesses signature on facility consent form &advocates for patient

describe perioperative nursing measure that reduce the risk for infection and other post operative complications

To post-anesthesia care unit (PACU) until stable: Respiratory: airway, rate & effort, lung sounds, pulseoximetry Cardiac: rate & rhythm, BP, temp, skin color, caprefill Neurologic: LOC, orientation, pupil size & reactivity,

motor status Urinary: fluid balance Surgical site Pain management Immediately following transfer to unit from PACU:- Frequent vital signs: q 15 min x 4, q 30 min x 2, q 1hour x 1; more often if unstable- Ongoing focused assessment: respiratory, cardiac,neurological, urinary, surgical site & pain status When above completed & pt stable, continue routinepostop vital signs & assessments per facility policy orMD order

Identify surgical risk factors for the adult patient and nursing interventions to reduce these risks

Respiratory

Atelectasis: alveolar collapse from mucus blockage Pneumonia: microbes invade stagnant mucus in lungs Management: deep breath, cough, hydrate, turnCardiovascular Deep vein thrombosis (DVT), syncope Management: leg exercises, avoid crossed legs orpillows under knees; dangle before ambulation

Urinary Dysuria, urinary retention, oliguria Management: assist to void (gravity position, run water)monitor for retention, straight cath if necessary

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GI Sore throat, nausea/vomiting, constipation, distension Management: hot/warm fluids as ordered (avoid ice &carbonation until passing flatus), early/regularambulation, progress diet as tolerated, the bomb

Integumentary

Infection & delayed healing (obesity, poorcirculation) Management: assess drainage color, amount, odor,VS (fever >100.4 in 1st 48 hrs or > 99.9 after 48hours significant) & notify MD if s/sx infectionPain Incision, positioning, movement, muscle spasms,tension from anxiety Management: analgesics, positioning, pillows,progressive relaxation, notify MD if ineffective

3 differebt areas of surgery dept and proper attire for each

Surgical Department AreasUnrestricted (holding) area: Where patients enter, staff locker room Street clothes okaySemi-restricted area: OR corridors & support areas. Only authorizedpersonnel Surgical attire; head/facial hair covered, shoe coversRestricted area: Operating rooms, scrub sink areas Masks worn in addition to surgical attire

Inertdiipline area approce to nursinf care during surgery

This interdisciplinary system facilitates the identification of patient problems and nursing diagnoses as

well as patient care orders. The selected nurses' and physicians' orders are integrated and organized by

care plan categories in printouts.

Role of the nurse in ensuring pt safety dring the interoperative period

Surgery PreparationRN prepares patient: Preoperative assessment & interview Current medication use Lab & diagnostic study results review Ensure recent history & physical exam in chart Preop checklist: signed consent; NPO; remove jewelry,dentures & contacts Skin prep: may include shave/clip hair, scrub Preoperative teaching: what patient can expect Administer ordered preoperative meds

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Respiratory Atelectasis: alveolar collapse from mucus blockage Pneumonia: microbes invade stagnant mucus in lungs Management: deep breath, cough, hydrate, turnCardiovascular Deep vein thrombosis (DVT), syncope Management: leg exercises, avoid crossed legs orpillows under knees; dangle before ambulation

Urinary Dysuria, urinary retention, oliguria Management: assist to void (gravity position, run water)monitor for retention, straight cath if necessaryGI Sore throat, nausea/vomiting, constipation, distension Management: hot/warm fluids as ordered (avoid ice &carbonation until passing flatus), early/regularambulation, progress diet as tolerated, the bomb

Integumentary Infection & delayed healing (obesity, poor

circulation) Management: assess drainage color, amount, odor,VS (fever >100.4 in 1st 48 hrs or > 99.9 after 48hours significant) & notify MD if s/sx infectionPain Incision, positioning, movement, muscle spasms,tension from anxiety Management: analgesics, positioning, pillows,progressive relaxation, notify MD if ineffective

geritologic conditions to post operative wound managementCommon to have surgical pts > 65 Biologic age more significant than chronologic Risks of complications increases with age Identify baseline functional & cognitive status Consider deficits in hearing, vision, mobility

Assess for fall risk Allow extended time for preoperative teaching

Itean nursing assessment and management after transfer from the pacu to the general