Implementing Flashcards
There are three (3) considerations for implementing care, what are they as it relates to a client or a patient ?
1) Developmental age & psychosocial background, 2) Ability & willingness to participate in the POC. 3) Response to nursing measures and progress toward goal achievement
What steps are included in implementing?
Carry out the plan 2) Continue with data collection & modify the POC as needed 3) Documenting
Why is implementation done in nursing ?
To promote health & prevent disease & illness, restore health & facilitate coping
What is Alfaro’s rule?
Assess, reassess, revise, record
True or False, Always monitor the patient’s responses to your interventions so that you can modify the care plan if needed.
True
Why does a nurse reassess a POC?
Because changes in status that might dictate a different set of interventions.
According to implementing guidelines, does the nurse involve only the patient or client? Yes or No
No include the family if available
According to implementing guidelines, and before implementing, what is a necessary step a nurse should take?
Reassess the patient to determine whether the action is still needed.
How are nursing interventions modified?
(1) developmental and psychosocial background, (2) ability and willingness to participate in the care plan, and (3) responses to previous nursing measures and progress toward goal/outcome achievement.
Think about the Implementing Guidelines #2, nursing interventions selected are consistent with what?
Standard of Care and with legal and ethical guidelines to practice.
There are six (6) types of nursing interventions, can you name them?
Direct Nursing Interventions
Indirect Nursing Interventions
Those aimed at individuals, family, and community
Nurse-initiated interventions
Provider-initiated treatments
Collaborative nursing interventions
Protocols are written plans that detail the nursing activities to be executed when? Give an example?
Executed in specific conditions-hold if B/P<, Hold if Apical rate <60
True or False Standing orders initiate routine actions for the nurse without the need of another provider
True
What is an action performed away from the client or patient, but on their behalf?
It is an indirect nursing intervention
What are some examples of an indirect nursing intervention? Select all that apply
1. Making referrals for PT
2. A case conference with the discharge planner
3. A needs assessment
4. A nurse meets with the collaborative care team to plan nursing measures for a patient.
1-4 all are correct
What are the steps to implement the plan of care (POC) ?
Reassessing the patient and reviewing the care plan
Clarifying prerequisite nursing competencies
Organizing resources
Anticipating unexpected outcomes/situations
Preventing errors and omissions
Promoting self-care: teaching, counseling, and advocacy
Assisting patients to meet outcomes
What are the patient or client variables which can influence an outcome?
Developmental stage
Psychosocial background and culture
What are the nursing variables which can influence an outcome?
Resources
Current standards of care
Research findings
Ethical and legal guides to practice
Which example illustrates a nurse variable influencing patient outcomes? Select the best answer.
A. patient in a nursing home refuses to take his medications.
B. A low-income family is unable to afford formula for their newborn infant.
C. An alcoholic patient is unwilling to participate in AA meetings.
D. A rape victim does not receive counseling in the emergency department because a counselor is not available.
D. Only D is correct because nurse variables that influence the POC also includes resources. The other selections or answers are about patients-
They are eight (8) common reasons for noncompliance, can you name them?
Developmental level
Lack of family support
Lack of understanding about the benefits
Low value attached to outcomes
Adverse physical or emotional effects of condition
Adverse physical or emotional effects of treatment
Inability to afford treatment
Limited access to treatment
What are actions, a nurse can do for noncompliance ?
Reassess
Assess the reason for noncompliance
Re-Strategize
Collaborate, negotiate, compromise with patient
Avoid judgement
** There are five (5) Rights of Delegation, what are they? ***
Right task
Right circumstances
Right person
Right directions and communication
Right supervision and evaluation
True or False -Document all nursing interventions?
True
