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Define characteristics of goals Must be realistic, measurable. Time frame must be established. Can be immediate, intermediate, long term.
Example of immediate goal Stand be bed for 5 minutes within 12 hours of surgery
Example of intermediate goal Ambulate to bathroom using walker as needed.
Example of long term goal Ambulate independently 1-2 miles per day.
How is a goal derived from a nursing diagnosis One framework is Maslow's hierarchy. Prioritize from urgent to less urgent.
Once diagnoses are prioritized, the _______________ need to obtain these goals can be identified nursing interventions
Once nursing interventions are identified, __________________ can be established outcomes
outcomes must be ________ and ___________ and have a ______ ________ for completion realistic and measurable. Time frame
NOC Nursing Sensitive Outcome Classifications
Example of Nursing Diagnosis Acute pain RT inflammed appendix RF infection RR dehydration due to vomiting Ineffective coping due to stresses at home
Examples of Nursing Goals - Immediate See Smelzer page 37 -Relief of pain -Prevent fluid volume deficit and electrolyte imbalance -Promote rest
Examples of Nursing Goals - Intermediate -Initiation of lifestyle alterations to decrease stress
Examples of Nursing Goals - Long term -Alter diet so as to manage health complications -Institute regular exercise to manage stress
Nursing Intervention - Define `To achieve desired goals and outcomes, the nurse, along with input from patient and significant others, identifies individualized interventions to address each outcome.
Independent Nursing Intervention` completely within scope of nursing practice -Hygiene, comfort, food
Dependent Interventions Require input from add'l source
Interdependent Carrying out prescribed treatments, administering meds & therapies, collaboration with other health care team members to achieve specific goals and outcomes.
Define Actual as a problem status Exist at the time of the assessment.
Define At Risk For as a problem status Conditions that the patient is vulnerable to if the nurse does not intervene to prevent.
Give example of a standardized wellness (health promotion). See page 35, chart 3-7 -Promotion of an optimal spontaneous breathing pattern that maximizes oxygen and carbon dioxide in the lungs. -Maintain patent airway. Ambulate 3-4 times per day. Administer meds. Teach breathing technique.
Define implementation Actual action phase of the Nursing Process; involves carrying out the proposed plan of nursing care.
The 3 Types of goals are... Immediate, Intermediate and Long-term
Goals are based on ______________ which are based on Nursing Diagnoses which are based on ___________________. Goals are based on Nursing Interventions which are based on Nursing Diagnoses which are based on Maslow Heirarchy of Needs.
"Relief of Pain" is an example of what type of goal? Immediate
"Alteration of lifestyle" is an example of what type of goal? Long-term
"Early detection of any complications" is an example of what type of goal? Immediate
"Initiation of lifestyle alterations to decrease stress and facilitate rest" is an example of what type of goal? Intermediate
Define nursing intervention. In planning appropriate nursing actions to achieve the desired goals and outcomes, the nurse identifies individualized interventions based on the patient’s circumstances and preferences that address each outcome.
Assisting with hygiene care, promoting physical & psychological comfort, facilitating ingestion of nutrients, and carrying out a variety of therapeutic nursing activities are all examples of _____________ Nursing Interventions. INDEPENDENT Nursing Interventions b/c each of these actions are w/in the scope of practice
Carrying out prescribed treatments and administering medications & therapies are examples of ______________ Nursing Intervntions. INTERDEPENDENT Nursing Interventions b/c the nurse must collaborate with other health care team members to accomplish specific expected outcome.
_______________________ are conditions that the patient is vulnerable to if the nurse does not intervene to prevent it. These must be addressed in the _____________________ to maintain patient’s health and improve patient outcomes. Potential problems or “Risk For/RF” are conditions that the patient is vulnerable to if the nurse does not intervene to prevent it. These must be addressed in the nursing interventions to maintain patient’s health and improve patient outcomes.
Define implementation. Actual “action” phase of the Nursing Process involves carrying out the proposed plan of nursing care
Created by: Marshall3