Ch. 9 Flashcards
What should the nurse consider before implementation of all nursing interventions?
Potential communication barriers.
Diverse cultural practices.
Scope of nursing practice.
Functional status of the patient
Which intervention would be most important for the nurse to include in the care plan if the patient is unable to complete activities of daily living without becoming fatigued?
Encourage the patient to rest between activities
Which nursing intervention is most important to complete before giving medication to a patient?
Double check the patients allergies before giving the drug
Which direct care intervention would be most effective in helping a patient cope emotionally with a new diagnosis of cancer?
Encouraging the patient to explore options for care
What should be taken into consideration by the nurse when deciding on interventions to include in a patient’s plan of care?
Patients treatment preferences.
Cultural and ethnic influences.
Professional level of expertise.
Current evidence based research
Which task may the RN safely delegate to a UAP without prior intervention?
Transporting a patient to the hospital entrance for discharge.
Which actions are a part of the evaluation step in the nursing process?
Recognizing the need for modifications to the care plan.
Reviewing whether a patient met the short term goal
Which action by the day shift nurse provides objective data that enables the night shift nurse to complete an evaluation of a patients short term goals?
Documenting patient assessment findings in the patients chart
Which notation is most appropriate for the nurse to include in a patients chart regarding evaluation of the goal, “patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)?”
Goal met; patient ambulated three times in the hallway without SOB.
What is the primary purpose of quality improvement?
Enhancing current practice to improve patient outcomes and care
Describe the relationship between care plan modification and quality improvement
Care plan modification is based on the effectiveness of interventions to meet and improve desired patient outcomes.
QI processes benefit patients and ultimately affect patient care.
If certain patient outcomes are consistently improved by the implementation of specific nursing interventions, procedures can be changed on the basis of the QI research.
Apply evaluation principles used in the nursing process
Evaluation focuses on the patient and the patients response to nursing interventions and outcome attainment.
Evaluation is not a record of the care that was implemented.
Info on the effectiveness of nursing interventions is a by-product of the evaluation process.
Nurses use critical thinking to determine whether a patients short and long term goals were med and the desired outcomes were achieved.
Identify the significance of documentation in the implementation step
Nurses must document effectively to convey information accurately to other care providers.
Within HIPAA guidelines, patient documentation is provided to insurance companies and others for billing and reimbursement
Recognize dependent nursing interventions
Tasks the nurse undertakes that are within the nursing scope of practice but require physician orders. Required to pay strict attention to the details of what was ordered and to recognize when implementing a dependent nursing intervention is appropriate or should be withheld in consultation
Identify examples of independent nursing interventions
Tasks within the nursing scope of practice that don’t require physician orders.
Extent to which nurses can implement independent interventions is determined by the area in which care is taking place
Differentiate among various forms of indirect care interventions
Indirect care includes nursing interventions performed to benefit patients without face to face contact.
Includes communicating and collaborating with other health care team members, making referrals, doing research, advocating, delegating and engaging in preventive actions (patient education and health promotion)
Describe different types of direct care interventions
Direct care refers to interventions that are carried out by having personal contact with patients.
Direct nursing interventions include reassessing patients, assisting with ADLs, giving physical care, counseling and teaching.
Explain the significance of implementation and evaluation in the nursing process
Nurses and other members of the health team provide care through interventions designed to promote, maintain, or restore a patients health during the implementation phase.
Consists of performing a task and documenting each intervention.
Evaluation focuses on the patient and patients response to nursing interventions and outcome attainment.
Eval data are used by the nurse to adapt a plan of care on the basis of patients changing health status.
QI quality improvement
Formal way to look at patient and treatment outcomes and to determine what can be done differently to affect a situation in a positive way.
Benefits patients and ultimately affect patient care
Care plans should…
Be updated regularly after patient evals.
Ongoing in an attempt to meet patient needs.
If patient goals are not achieved the nurse reflects on:
What barriers did the patient have in meeting these goals?
Were the goals realistic?
What happened that was not anticipated?
What can be done differently?
Reassessment should occur…
Every time the nurse interacts with a patient or reviews updated diagnostic lab tests
Goal attainment and changing circumstances
reasons why plan of care is discontinued
Revised or adapted
When patient goal is unmet or partially met
When complications arise or goals are not met…
The nurse revises the plan of care in response to the eval findings
Evaluation process begins…
With determining whether patient goals have been met.
Evaluation examines the extent to which interventions affected patient outcomes
Medical treatments
Dependent nursing interventions
Ex. Urinary catheterization, 24 hour urine collection, dressing changes, incision irrigation, intubation, and placing NG tubes
Medication administration
Within scope of nursing practice but is dependent.
Nurses must omelet three checks and follow 6 rights of med administration.
Check physicians order, patient allergies, and expiration date
6 rights of medication administration
- right medication
- right dosage
- correct route
- right patient
- right time
- correct documentation
Standing orders
Preapproved.
Ex. Patient return to room after cardiac catheterization, standing order is that the patient remains on bed rest for specific amount of time. The nurse is to maintain patient on bed rest for requested amount of time
Informal counseling
Provide a listening ear.
Stimulate patients thought process or decision making process.
May occur when faced with new diagnosis
Physical care
Performed when treating patients.
Invasive/noninvasive procedures
ADLs
Activities of daily living
Important to assess where deficits exist and determine whether patients require short or long term interventions to address their needs
Reassessment
Continuous to detect noticeable changes in condition, and adjustments to current interventions.
Direct care
Interventions that are carried out by having personal contact with patients
Implementation
Consists of performing a task
Teaching
Essential professional nursing intervention.
Each interaction with a patient is an opportunity to teach
Indirect care
Performed for patients but do not involve face to face contact with patient
Communication and collaboration
Essential for patient safety and positive patient outcomes
Referrals
Involve sending a patient to another member of the health care team or agency for consultation
Research
Evidence based care involves interventions provided by all members of health care team
Advocacy
Supporting and working on behalf of the patient or people for whom they have concern
Delegation
Transfer of responsibility for performing a task to another person while the nurse who delegated is held accountable.
Indirect intervention
Prevention oriented interventions
Prevent illness or complications and promote healthy activities or lifestyles
