Download implementing nursing care notes and more Lecture notes Nursing in PDF only on Docsity!
CH. 19 Implementing Nursing Care - 4
th
step in
nursing process
Introduction Implementation begins after you develop a patient’s plan of care Nursing intervention Ø Any treatment based on clinical judgment and knowledge that a nurse performs to enhance a patient outcomes. Direct care interventions Ø Treatments nurses provide through interactions with patients or a group of patients Indirect care interventions Ø Treatments performed away from a patient but on behalf of the patient or group of patients Ø Documentation Ø Interprofessional collaboration Nursing Interventions Scope of Practice
Standard Nursing Interventions (1 of 3) Standard interventions Ø Allow nurses to act more quickly and appropriately Ø Help capture patient care information that can be shared across disciplines and care settings Nurse- and health care provider–initiated standard interventions include Ø Clinical practice guidelines and protocols Ø Care bundles Ø Standing orders Ø Nursing Interventions Classification (NIC) interventions Ø Standards of practice Standard Nursing Interventions (2 of 3) Clinical practice guidelines and protocols Ø A systematically developed set of statements about appropriate health care for specific health care problems or clinical situations Care bundle Ø Group of interventions related to a disease process or condition Standing orders Ø Preprinted document containing medical orders for routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. Ø Directs patient care in a specific clinical setting Standard Nursing Interventions (3 of 3) Nursing interventions classification interventions (NIC) Ø Common interventions recommended for various nursing diagnoses Standards of practice Ø Nurses use the ANA Standards of Professional Nursing Practice as evidence of the standard of care provided to patients Quality and safety education for nurses (QSEN) Ø Standard competencies in knowledge, skills, and attitudes for the preparation of future nurses Critical Thinking in Implementation (1 of 2) Framework for how to make decisions when implementing nursing care When making decisions: Ø Review the set of all possible nursing interventions for a patient's problem. Ø Review all possible consequences associated with each possible nursing action. Ø Determine the probability of all possible consequences. Ø Judge the value of the consequence to the patient.
Implementation Skills You are responsible for knowing when one type of implementation skill is preferred over another and for having the necessary knowledge and skill to perform each. Ø Cognitive skills Ø Interpersonal skills Ø Psychomotor skills Direct Care Activities of daily living (ADLs) Ø Direct care measures usually performed during a normal day. Ex: ambulating Instrumental ADLs (IADLs) Ø Activities that support daily life and are oriented toward interacting with the environment, daily life activities. Ex: shopping, house cleaning, preparing meals Physical care techniques Ø The safe and competent administration of nursing procedures Ø Type of direct care, Lifesaving measures Counseling Teaching Controlling for adverse reactions Preventive interventions Ø Prevent illness to avoid the need for acute or rehabilitative health care Ø Primary prevention: aimed at health promotion (health edu programs, immunizations, physical and nutritional activities Ø Secondary prevention: focuses on people who are experiencing health problems & at risk for developing complications (screening techniques, treating early stages of disease) Ø Tertiary prevention: involves minimizing the effects of long term illness or disability (rehab measures) Indirect Care Nursing treatments or procedures performed away from a patient(s) but on behalf of a patient Communicating nursing interventions Ø Written or oral Delegating, supervising, and evaluating the work of other staff members Achieving Patient Goals Nurses implement care to meet patient goals and expected outcomes. Priority setting helps nurses to anticipate and sequence nursing interventions. Patient adherence means that patients and families invest time in carrying out required treatments. Introduce implementation measures that patient are willing and able to follow. Quick Quiz 1
- Nurse-initiated interventions are A. determined by state Nurse Practice Acts. B. supervised by the entire health care team.
C. made in concert with the plan of care initiated by the physician. D. developed after interventions for the recent medical diagnoses are evaluated. Quick Quiz 2
- You are writing a care plan for a newly admitted patient. Which one of these outcome statements is written correctly? a. The patient will eat 80% of all meals. b. The nursing assistant will set the patient up for a bath every day. c. The patient will have improved airway clearance by June 5. d. The patient will identify the need to increase dietary intake of fiber by June 5. EAQ CH.
- Which feature is true about standing orders? a. Me instrumental activities of daily living b. ensure familiarity with evidence-based guidelines for nursing care c. allow a quick response to a rapidly changing clinical situation d. minimizes documentation issues for nurses
- Which response would the nurse make for a patient who expresses confusion about how to manage a leg wound after discharge? a. Provide a written document that contains the necessary instructions b. tell the patient that a relative will be taught how to take care of the wound c. explain and demonstrate the necessary action to the patient d. informed the patient that it will be explained later during discharge
- Which priority action would the nurse take before administering a new drug? a. Confer with the colleague before giving the medication b. consult with the pharmacist to obtain knowledge about the medication c. ask the patient about the medication d. administer the medication as prescribed and on time
- Which action indicates that the nurse is using physical care techniques? a. Meeting the patient expressed needs b. performing indirect care measure c. using safe patient handling procedures d. providing a handoff report
- Which action would the nurse take when the patient who is nothing by mouth (NPO) (no fluids or food allowed) develops an adverse reaction to a new IV drug? Select all that apply a. record the reaction b. stop further administration of the drug c. notify the health care provider
