Chap 9- Implementation & Evaluation Flashcards
action phase where plan of care is carried out/ where nursing care is provided to help pt reach functional health
implementation
A nursing action is a
intervention
Implementation Activities inclue
Reassesment
Set Priorities
Rank priorities
Perform Nursing Interventions
Documentation
Implementation Skills
Problem Solving,
Decision Making
Teaching
Interpersonal Skills
Technical Skills
How do you know a plan of care is not working?
The patient is not making progress
What should the nurse do, when current plan of care is not working?
Reassess patient to find out what modifications are need to be made to plan of care
phase where effectiveness of the nursing plan of care is judged based on the patient’s responses
Evaluation
What should be executed during implementation?
The Plan of Care
Evaluation is not a continuous process. T or F
False. Evaluation IS a CONTINuOUS process
Nurses should be documenting if a goal is met or not, and why it was or wasnt. T or F
True
SHould pt responses be monitored?
Yes
Why is evaluation important?
helps the nurse find errors, changes that need to be addressed
What is the FOUNDATION for evaluation?
The Care Plan
Evaluation Skills
-Knowledge of Standards of Care
-Knowledge of patient’s normal response
-Ability to monitor the effectiveness of the nursing intervention
Evaluation Activities
Observe pt behavior
Use Documentation of pt response to interventions
Collect Subj and Obj Data
Were Goals Completed?
Are there new problems?
New interventions
You can add new interventions to an existing problem?
Yes
Patient’s Health Record is NOT a legal document. T or F
False, Medical Records are a LEGAL DOCUMENT
eMAR stands for
electronic health admin record
Two parts of an eMAR are
Standing orders- routine meds
PRN- as needed
What happens when “abnormals” are documented?
Intervention is required. Reassessment is required.
Documentation should be
short, complete, concise, ACCURATE
ISBAR
Identification
Situation
Background
Assessment
Recommendations
Can verbal orders be given/taken?
NO; MD must write or input whatever they tell you
What is rounding?
Checking on Patient regularly
What is a huddle?
A meeting about all the pts on the floor
What is a Kardex?
nursing cheat sheet that can be used throughout the day. should be discarded by EOD
Charting by Exception
only document on/ by patient’s problem
Who decides how/ which method is used when you chart?
Decided by facilities Policy & Procedures
Narrative Note-
a little story about patient/ block note
SOAP note
Subjective
Objective
Assessment
Plan
APIE note
Assessment
Plan
Intervention
Evaluation
FOCUS or DAR note
Data- Subj/Obj
Action
Response
