Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide Identification of Goals or Expected Outcomes A goal or expected outcome for the patient is a statement of a measurable change in the behavior or health status, which may be responsive to nursing interventions. The goals or outcomes for the patient will be: • Established through collaboration with the patient, family, and other healthcare team members • Patient-centered, describing what the patient will be able to do or what the patient’s health status will be • Individualized for the patient, taking into account all the data available about thepatient • Based on the nursing diagnoses established with the patient • Observable and measurable • A combination of short term and long-term goals: o Short term goals are those that can be attained within a few hours or days. For example, the patient with “activity intolerance R/T imbalance oxygen supply/demand AEB shortness of breath when walking” might have a short-term goal of, “the patient will use the incentive spirometer five times after every two hours while awake.” o Long term goals are those that will require a longer time for resolution and may extend beyond the current hospitalization. For the patient with activity intolerance, a long-term goal might be, “The patient will increase activity tolerance and be able to walk one mile with no signs of shortness of breath.” The Nursing Outcomes Classification (NOC) is a standardized classification of patients’ outcomes that was developed in the beginning of 1991, at the University of Iowa, and has been recognized by the American Nurses’ Association as one of the approved nursing standard languages. This classification can be used in conjunction with the NANDA Taxonomy of Nursing Diagnoses and the Nursing Interventions Classification. Outcomes developed with the patient may be related to health promotion, maintenance, or restoration. Outcomes will be realistic and reflect attainable goals because they are individualized for the patient. Once the expected outcomes are identified, the team will develop the nursing interventions for reaching the goals. Identification of Nursing Interventions Nursing interventions are the actions that are performed by the nurse (or another member of the team) that will help the patient achieve the outcome and the goals. When planning nursing interventions for a patient, there are several standards that must be considered including: • The nurse practice act: Each state has a nurse practice act that defines the scope of practice for a nurse in that state. The nurse practice act defines what a nurse can and cannot legally do. It is critical that the nurse knows the scope of practice in the state where she is licensed. Practicing outside of that scope can lead to revocation of the nurse’s license and can lead to other legal actions.

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