Chap 9- Implementation & Evaluation Flashcards

1
Q

action phase where plan of care is carried out/ where nursing care is provided to help pt reach functional health

A

implementation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

A nursing action is a

A

intervention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Implementation Activities inclue

A

Reassesment
Set Priorities
Rank priorities
Perform Nursing Interventions
Documentation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Implementation Skills

A

Problem Solving,
Decision Making
Teaching
Interpersonal Skills
Technical Skills

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How do you know a plan of care is not working?

A

The patient is not making progress

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What should the nurse do, when current plan of care is not working?

A

Reassess patient to find out what modifications are need to be made to plan of care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

phase where effectiveness of the nursing plan of care is judged based on the patient’s responses

A

Evaluation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What should be executed during implementation?

A

The Plan of Care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Evaluation is not a continuous process. T or F

A

False. Evaluation IS a CONTINuOUS process

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Nurses should be documenting if a goal is met or not, and why it was or wasnt. T or F

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

SHould pt responses be monitored?

A

Yes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Why is evaluation important?

A

helps the nurse find errors, changes that need to be addressed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is the FOUNDATION for evaluation?

A

The Care Plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Evaluation Skills

A

-Knowledge of Standards of Care
-Knowledge of patient’s normal response
-Ability to monitor the effectiveness of the nursing intervention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Evaluation Activities

A

Observe pt behavior
Use Documentation of pt response to interventions
Collect Subj and Obj Data
Were Goals Completed?
Are there new problems?
New interventions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

You can add new interventions to an existing problem?

A

Yes

17
Q

Patient’s Health Record is NOT a legal document. T or F

A

False, Medical Records are a LEGAL DOCUMENT

18
Q

eMAR stands for

A

electronic health admin record

19
Q

Two parts of an eMAR are

A

Standing orders- routine meds
PRN- as needed

20
Q

What happens when “abnormals” are documented?

A

Intervention is required. Reassessment is required.

21
Q

Documentation should be

A

short, complete, concise, ACCURATE

22
Q

ISBAR

A

Identification
Situation
Background
Assessment
Recommendations

23
Q

Can verbal orders be given/taken?

A

NO; MD must write or input whatever they tell you

24
Q

What is rounding?

A

Checking on Patient regularly

25
Q

What is a huddle?

A

A meeting about all the pts on the floor

26
Q

What is a Kardex?

A

nursing cheat sheet that can be used throughout the day. should be discarded by EOD

27
Q

Charting by Exception

A

only document on/ by patient’s problem

28
Q

Who decides how/ which method is used when you chart?

A

Decided by facilities Policy & Procedures

29
Q

Narrative Note-

A

a little story about patient/ block note

30
Q

SOAP note

A

Subjective
Objective
Assessment
Plan

31
Q

APIE note

A

Assessment
Plan
Intervention
Evaluation

32
Q

FOCUS or DAR note

A

Data- Subj/Obj
Action
Response