ASSESSMENT/EVALUATION
The location of care plans in Essentris.
Where is the care plan tab in the notes menu?
1. Actual-Problem Focused
2. Health Promotion
3. Risk
4. Syndrome
5. Possible
What are the five types of nursing diagnoses?
Improved patient outcomes.
What is the purpose of care plans?
Implement and document patient specific interventions every shift.
What are mandatory shift tasks.
The hospital plans the patient’s care, treatment, and services based on needs identified by the patient’s assessment, reassessment, and results of diagnostic testing.
What is 1 of the 2 identified Joint Commission Standards related to care plans?
The first step in the nursing process.
What is assessment?
Name at least one care plan appropriate for a patient readmitted following non-adherence to new medications and inability to verbalize definition of heart failure.
What are: Medication Non-compliance
Knowledge Deficit
Cardiac Output
Volume Excess
Measure a wound. Have patient demonstrate self glucose testing. Observe patient's ability to perform ADL's.
What are methods to assess/ evaluate if interventions are meeting expected outcomes?
Erase non-applicable generic interventions during care plan initiation.
What I do when pre-populated intervention to not apply to patient presentation and assessment data.
How we ensure the patient and family can visualize goals/ expected outcomes and care team.
What is the in-room daily communication board?
Documentation of evaluation/ status update/goals met/ unmet.
What is the final step at shift-end of care plan completion?
1. Diagnosis
2. Related to
3. Evidenced by
What are the three parts of a nursing diagnosis?
measurable, realistic, time-limited, observable
What are outcome components?
Putting the plan into action.
What is implementation?
Use the blank PROB Template.
What is done when a nursing assessment reveals the need for a care plan topic not available in Essentris?
Data that includes: Previous AHLTA notes, H&P, Lab values, Diagnostic studies
What is an example of objective data?
Data that includes: "I have pain all the time" "I have had 3 falls at home" "I don't know my medications"
What are examples of subjective data?
A specific measurable change that was anticipated in response to interventions.
What is an expected outcome?
obtaining vital signs, ambulating a patient, recording fluid intake, prevent falls, turn/ re-position patient Q2H, etc.
What are examples of interventions that can be delegated?
Care plans are resolved, care plan compliance rates increase, re-admissions are prevented and The Joint Commission acknowledges unit compliance
What happens when nurses document that 4D patients have meet their goals?
The care plan most appropriate for a patient that reports being scared of the doctor and blood work, is afraid of “relying on a machine to live” and is fearful of the future while appearing tense.
What is Anxiety related to Lack of knowledge as evidenced by Feelings of apprehension
NANDA-I
What is North American Nursing Diagnosis Association-International?
N.O.C.
What is a nursing outcome classification?
N.I.C.
What is a nursing intervention classification?
The written plan of care is based on the patient’s goals and the time frames, settings, and services required to meet those goals.
What is 1 of the 2 identified Joint Commission Standards related to care plans?