Clinical Assessment Preparation

CPNE Study Guide

• Outcome Statement:  One measurable expected patient outcome related to diagnostic label  3 components: 1. Realistic and clearly states what a patient will be able to do as a result of interventions 2. Measurable: Can be seen, heard, or felt 3. Consistent with and can result in the resolution of the identified ND  Should include only one behavioral measurement, using one action verb  Outcomes and interventions should not have the same wording • Example: ND: Impaired comfort r/t abdominal surgery AEB pt statement of “I feel really uncomfortable because of this incision to my abdomen” and patient rated his comfort level at a 3 on a comfort verbal scale of 0-10. Expected outcome: The patient will state a 5 or HIGHER on the VERBAL COMFORT SCALE after interventions. • Are the patient outcomes…?  Clearly stated  Realistic and safe  Acceptable to patient and family  Written in patient-centered terms  Specific and concrete; directly observable  An action behavior that can be completed during the PCS • Interventions:  Two nursing interventions that relate to each diagnostic label and the associated patient outcome  Specific action moving the patient toward resolution of the ND  One action per intervention  Cannot be assessment interventions  All interventions must be carried out during PCS  Ask yourself… 1. Will I be able to evaluate the effectiveness of the interventions during the PCS? 2. If I perform these interventions, will the patient achieve the stated outcome? 3. Will the examiner know when I’m performing the interventions based on what is written on the NCP? • Example: Expected outcome: The patient will state a 5 or HIGHER on the VERBAL COMFORT SCALE after interventions. Interventions: Assist with repositioning the patient in bed once during the PCS, teach the patient guided imagery as an alternative comfort relief measure during PCS.  Each intervention should be… • Specific/realistic • Adhere to medical regimen • Appropriate to the ND and expected outcome • Consistent with standards of safe nursing practice • Consistent with legal and ethical practice • Linked to assigned areas of care

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