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 Specific Measurable Attainable Realistic Time-targeted

DESCRIBE HOW GOALS ARE ESTABLISHED
Goals should:
- Resolve or reduce the problem - Be attainable & realistic in time frame specified - Represent a greater level of
achievement for client - Not conflict with MD orders
• Establish goals mutually with patient if possible/Describes behavior that: Nurse can measure objectively OR
Patient can measure subjectively

DIFFERENTIATE BTWN LTG AND STG

LTG-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 achieving
long- term goals

IDENTIFY THE CHARACTERISTICS OF AN ACCURATELY FORMULATED GOAL STATEMENT

Diagnostic 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: (Patient’s) 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 patient’s response to interventions & degree of goal achievement

WEEK 8
DEFINE AND DISCUSS THE PURPOSE OF IMPLEMENTATION AND EVALUATION
Implementation
• Action phase of nursing process • RN sets Interdisciplinary plan in motion
- Communicates plan to health care team
- Supervises/delegates responsibility as
indicated
- Team reports significant findings back to RN
Implementation Skills
• Cognitive • Interpersonal • Psychomotor
Reassess to make sure needs unchanged
• Determine need for assistance • Explain to patient:
- What is to be done & why (rationale)
- What to expect & what expected to do
• If it isn’t documented:
- You didn’t do it (legal)
- Patient may receive it twice (safety)
EVALUATION-• Determine effectiveness of nursing care
• Analyze success of goals & interventions
• Incorporates input from team and patient
• Cyclical - leads back to assessment
EVAL. ACTIVITIES:Collect data • Examine response to interventions & compare with goals
• Record goal attainment • Revise/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 team
and patient Cyclical - leads back to assessment• Collect data Examine response to interventions & compare with
goals 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 care

• Analyze success of goals & interventions
• Incorporates input from team and patient
• Cyclical - leads back to assessment
EVAL. ACTIVITIES:Collect data • Examine response to interventions & compare with goals
• Record goal attainment • Revise/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 patient’s

feelings 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-containing beverages after noon & alcoholic
beverages just before bedtime. R: Caffeine is a CNS stimulant that lengthens sleep latency
and increases nighttime wakening. Alcohol induces drowsiness but suppresses REM sleep &
increases wakening (Craven & Hirnle, 2009) 3. Assess client’s subjective report of the quality
of her sleep each morning. R: Single most important criterion for adequacy of sleep & rest is
the client’s statement (Craven & Hirnle, 2009) 4. Cluster nursing activities to provide for
periods of uninterrupted 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 to experience a
full sleep cycle (Craven & Hirnle, 2009) STG: Verbalize 2 factors that inhibit sleep during my
shift 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 the
intervention is based-why you, as a nurse, performed the intervention and why it will
 assist in meeting the identified objectives and resolving the stated nursing diagnosis. It is
a 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 perform

surgery & ends when client in OR- Intraoperative: begins with entry into OR & ends
when 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, pulse
oximetry
• Cardiac: rate & rhythm, BP, temp, skin color, cap
refill
• 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 1
hour x 1; more often if unstable
- Ongoing focused assessment: respiratory, cardiac,
neurological, urinary, surgical site & pain status
• When above completed & pt stable, continue routine
postop vital signs & assessments per facility policy or
MD 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, turn
Cardiovascular
• Deep vein thrombosis (DVT), syncope
• Management: leg exercises, avoid crossed legs or
pillows 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
GI
• Sore throat, nausea/vomiting, constipation, distension
• Management: hot/warm fluids as ordered (avoid ice &
carbonation until passing flatus), early/regular
ambulation, progress diet as tolerated, the “bomb”

Integumentary
• Infection & delayed healing (obesity, poor
circulation)
• Management: assess drainage color, amount, odor,
VS (fever >100.4º in 1st 48 hrs or > 99.9º after 48
hours significant) & notify MD if s/sx infection
Pain
• 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 Areas

Unrestricted (holding) area:
• Where patients enter, staff locker room
• Street clothes okay
Semi-restricted area:
• OR corridors & support areas. Only authorized
personnel
• Surgical attire; head/facial hair covered, shoe covers
Restricted 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 Preparation
RN 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
Scrub Nurse/Scrub Tech
• Wears sterile garb, maintains sterility, works within
sterile field involved with sterile activities
• Prepares instrument table & sterile equipment, assists
with positioning sterile drapes
• Scrubs, gowns & gloves self & surgical team
• Hands instruments to surgeon & assistant
• Counts blood loss & irrigation fluid used
• Monitors aseptic technique practice in OR
• Counts needles, sponges, instruments
Circulating Nurse
• Does not wear sterile garb; works outside sterile field
• Prepares OR room; ensures items available
• Brings patient to OR, positions, applies monitors &
inserts catheter, supports pt during anesthesia
• Measures blood & fluid loss
• Records data & documents care during surgery
• Monitors aseptic technique practice in OR
• Counts needles, sponges, instruments
• Takes patient to PACU & reports to PACU RN

Role of nurse during interoperative period

Transport personnel usually OR staff who receive

report & paperwork from RN caring for patient
• Transport modes include: ambulation, wheelchair,
gurney, surgi-lift
• Let family know where to wait
• Prepare room for patient’s return: bed, pads, IV poles,
oxygen, suction, pillows etc

importance of safety in positioning of pt

• Surgical positioning: securing safely to expose surgical

site without compromising function
• Anesthetics cause muscle relaxation. Muscle stretch &
joint damage can occur
• Position in alignment, avoid pressure, promote
circulation, consider any preop problem areas
• Consider risk factors for injury: anesthesia type,
procedure type, length of surgery, required position,
patient’s overall condition

respomnisiblite sof post anestias care unit nurse in prevention of immediate post operative compications
To post-anesthesia care unit (PACU) until stable:

• Respiratory: airway, rate & effort, lung sounds, pulse

oximetry
• Cardiac: rate & rhythm, BP, temp, skin color, cap
refill
• Neurologic: LOC, orientation, pupil size & reactivity,
motor status
• Urinary: fluid balance
• Surgical site
• Pain management

Identify common post operative problem and there management

Respiratory
• Atelectasis: alveolar collapse from mucus blockage
• Pneumonia: microbes invade stagnant mucus in lungs
• Management: deep breath, cough, hydrate, turn
Cardiovascular
• Deep vein thrombosis (DVT), syncope
• Management: leg exercises, avoid crossed legs or
pillows 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
GI
• Sore throat, nausea/vomiting, constipation, distension
• Management: hot/warm fluids as ordered (avoid ice &
carbonation until passing flatus), early/regular
ambulation, progress diet as tolerated, the “bomb

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

geritologic conditions to post operative wound management

Common 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