Nursing 300 exam 2 Correct 100%

Goals/Nsg orders/interventions -ANSWER Review samples in syllabus and examples in class Setting priorities (Maslow) -ANSWER What would happen if I wait? ID probs w/ simple solutions? Need multidisciplinary teams? 1. Life threatening: physiological (needs to be met first like nutrition, hydration, O2, mobility, elimination) 2. Safety/security: fear, environ. hazards 3. Love/Belonging: isolation, loss of loved one 4. Self-esteem 5. Ability to achieve personal long term goals Essential focus for at least one goal in plan of nursing care -ANSWER Desired outcome of nsg intervention, written in terms of observable pt responses; if defined broadly must include specific, measurable outcomes Purpose: guide planning and evaluation, motivate ns and pt, measure sticks of care plan, direct nsg interventions, motivate *at least one goal must demonstrate resolution of problem*, essential pt goals from prob clause, goals from etiology clause could be achieved without resolving problem Examples of goals to critique -ANSWER See notes - must be SMART: specific, measurable, attainable, realistic/resources, time frame *do verbalized by pt, how much, time period* Long-term vs. short-term goals -ANSWER Short term: outcomes can be achieved with in a few days/hrs; usually must be achieved before pt can achieve long term goals Long term: pt outcomes over week or more; ideally aim at restoring normal functioning in problem area; if normal not possible describe max/optimum level of function that can be achieved Components of goals -ANSWER Subject: patient, characteristic of pt Action/Verb: one per goal Performance criteria: standards to evaluate quality of performance Target Time: how what when deadline Special Conditions: modifiers only if needed to clarify Goal vs. Outcome -ANSWER Goal: generally more broad Objective/Outcome: generally more specific Nsg Orders -ANSWER Activities and behaviors performed to change present pt responses to desired responses described in goals Ns does for pt, ns helps pt do for self, more specific and physicians orders Purpose of nsg orders -ANSWER Specific direction for care, *consistent individualized approach*, instructions for others to follow, guide documentation, promote quality care - primarily *target etiology* of a nsg dx - dec or eliminate causal, contributing, or risk factors or relieve symptoms - may also address problem cause of nsg dx, review pt goals Nsg orders address -ANSWER Observation: determine if complication develop, Pt's response (Ex. Assess lung sounds) Prevention: prevent complications, decr. risk factors (Ex. Monitor I/O, offer fluid) Treatment: treat existing problem (Ex. Give oral care or assist to amb) Health promotion: id areas for improve, not specific to dz, problem (teach to decr. fat in diet) Components of a Nsg order -ANSWER Date, subject (implied ns), action/verb, descriptive qualifiers (how, when, where, specific), specific times, signature Criteria for nsg orders -ANSWER Ns behaviors, individualized, specific, concise, consistent with standards of care, realistic, congruent with pt values, safe/moral/ethical, compatible with other therapies, *based on scientific rationale, EBP* Independent vs. Dependent nsg actions -ANSWER Independent: Ns legally able to carry out without another professional's order; ns prescribes & performs or delegates (Ex. Administer) Dependent: Ns. carries out prescriptions from Dr (Ex. give); Ns carries out in collaboration with oth