Nursing Process III

Question 1

Nursing Process III

Answer 1

Interventions
Implementation
Evaluation

Question 2

Nursing Process: Planning Interventions

To achieve planned outcome(s)

Answer 2

Question 3

What are nursing interventions?

• Their purpose is to achieve client outcomes
• Also called nursing actions, measures, strategies, activities
• Based on clinical judgment and nursing knowledge
• Reflect direct and indirect care

Question 4

?

Is care away from the client; acting on their behalf

i.e. advocating on a state level to benefit the concerns of a group

Answer 4

Indirect care

Question 5

?

Is care given directly to the client

i.e. administering a medication

Answer 5

Direct care

Question 6

Types of Nursing Interventions

Answer 6

Independent

Dependent

Interdependent

Question 7

?

When we are collaborative with other health team members; i.e. “something”/an activity, etc. in conjunction with PT, OT, or nutrition services

Answer 7

Interdependent

Question 8

?

The nurse is accountable for

NOT provider prescription orders

Nurse prescribes and performs these interventions in response to nursing diagnosis

Answer 8

Independent

Question 9

?

Is something prescribed by the provider and implemented by the nurse

Answer 9

Dependent

Question 10

Knowledge Check

The nurse teaches the client how to care for their indwelling urinary catheter at home. This is an example of which type of intervention?

a. Indirect
b. Independent
c. Dependent
d. Interdependent

Answer 10

Answer: b

We do not need a provider’s order to teach and we don’t have to collaborate with others on this (that’s interdependent)

Question 11

Choosing Nursing Interventions

Use

• Professional standards (i.e. ANA standards; we cannot delegate choosing interventions to other health team members)
• Theories
• Nursing research

Answer 11

Choosing Nursing Interventions cont’d

• Evidence-based guidelines

* The National Academies of Sciences, Engineering, and Medicine (formerly IOM)

* Safe, effective, nursing care (SENC) competencies

* Quality and Safety Education for Nurses (QSEN) competencies

• Be able to differentiate a clinical opinion from research and evidence summaries

Question 12

Evidence-Based Practice

• The goal is to identify the most effective, cost-effective treatments
• Uses scientific data
• Blends clinical judgment and expertise, research evidence, and client characteristics and preferences

Answer 12

Question 13

?

This term refers to what extent/effect does the data have?

Answer 13

Impact

Question 14

?

Term that refers to how useful the data is

Answer 14

Applicability

Question 15

?

Term that refers to how close is the data from the truth?

Answer 15

Validity

Question 16

Types of Research-Based Support

Answer 16

Single studies

Systematic reviews and meta-analysis

Clinical pathways and protocols

Evidence reports

Clinical practice guidelines

Question 17

?

These form the basis of nursing interventions

Are statements developed by systematic reviews of the evidence (reports)

Answer 17

Clinical practice guidelines

Question 18

?

Are standardized plans of care for frequently occurring situations; patients who have the same condition

May not be based on research; in accredited facilities they are

Answer 18

Clinical pathways and protocols

Question 19

?

Are systematic reviews of clinical topics that have a specific purpose of providing evidence

For when we are trying to find interventions that are evidence-based

Answer 19

Evidence reports

Question 20

?

Are found in nursing journals

Might not have all interventions; small population; 1 or 2 studies

Answer 20

Single studies

Question 21

?

These look at multiple single studies performed in various locations on the same topic

Answer 21

Systematic reviews and meta-analysis

Question 22

How does problem status influence nursing interventions?

Answer 22

Actual nursing diagnosis

Potential nursing diagnosis

Possible nursing diagnosis

Collaborative problem

Wellness diagnosis

Question 23

?

These are interventions that focus on optimal well-being

Answer 23

Wellness diagnosis

Question 24

?

Where risk for client doesn’t have the issue yet; interventions are focused on prevention

Answer 24

Potential nursing diagnosis

Question 25

? Where there is an actual problem Change in client status; interventions are based on restoring client health

Answer 25

Actual nursing diagnosis

Question 26

? These terms are interchangeable Are in conjunction with another member of the healthcare team (i.e. physicians)

Answer 26

Possible nursing diagnosis & collaborative problem

Question 27

Process Used for Generating and Selecting Interventions

Answer 27

Question 28

Standardized Language for Interventions Nursing Intervention Classification (NIC) - Each NIC intervention consists of a label, a definition, and a list of the specific activities nurses perform in carrying out the intervention - These are linked to our NANDA diagnoses and NOC outcomes

Answer 28

Standardized Language for Interventions cont'd The Clinical Care Classification The Omaha System

Question 29

? Involves standardized language used in community healthcare

Answer 29

The Omaha System

Question 30

? Involves standardized language used in home healthcare

Answer 30

The Clinical Care Classification

Question 31

Writing Nursing Orders Nursing orders are instructions that describe how and when nursing interventions are to be implemented \* Ensure orders are clear and that any nurse who picks up the order will interpret it the same way as was meant when it was written

Answer 31

Writing Nursing Orders cont'd A nursing order contains - Date - Subject (often the nurse) - Action verb (i.e. teach, offer, demonstrate) - Times and limits (i.e. when, how long) - Signature

Question 32

Safe Effective Nursing Care and Nursing Orders: Thinking, Doing, Caring Provide goal-directed, client-centered care - Establish mutual goals with client - Show respect for client values, religious beliefs, needs, and preferences - Implement interventions to promote client comfort

Answer 32

Safe Effective Nursing Care and Nursing Orders: Thinking, Doing, Caring cont'd Validate evidence-based research to incorporate in practice - Incorporate evidence-based findings into client care Provide safe, quality client care - Design a "Thinking, Caring, Doing" framework that incorporates a holistic approach to client care

Question 33

Nursing Process: Implementation and Evaluation

Answer 33

Question 34

What 3 items are involved in the implementation phase?

Answer 34

Doing Delegating Documenting

Question 35

Preparing for Implementation

Answer 35

Check your knowledge and abilities Organize your work \* Establish feedback points \* Prepare supplies and equipment Prepare the client

Question 36

Check your knowledge and abilities

Answer 36

- Clarify orders - Are we qualified/authorized to carry out the intervention? - Is the action safe, reasonable, and prudent?

Question 37

Organize your work

Answer 37

- What interventions can be done simultaneously?

Question 38

Prepare the client

Answer 38

- Reassess if the intervention is still necessary? - Assess client's readiness - Explain what we're going to do; what patient may feel; how much they need to be involved - Provide patient privacy

Question 39

Implementing the Plan

Answer 39

Use cognitive, interpersonal, and psychomotor skills Promote client participation \* A common issue is lack of understanding \* Provide teaching; be sensitive \* What are their concerns? \* Evaluate for change; get them to "buy in" Coordinate care \* Read and review reports of other professionals involved in the client's care

Question 40

Delegation and Supervision Transferring responsibility while retaining accountability Includes supervision (of UAP, LPN/LVN)

Answer 40

Delegation and Supervision cont'd That it gets done and was done correctly You cannot delegate any intervention that requires independent, specialized nursing knowledge, skill, or judgment

Question 41

What are the 5 rights of delegation?

Answer 41

Right task (can I delegate this task?) Right circumstance (Maybe I can delegate this task, should I?) Right person (Who is best prepared; do they have the proper skills?) Right direction/communication (What does the UAP or LPN/LVN need to know to carry the action out?) Right supervision (How do I, as the nurse, follow up to make sure that this was carried out and done correctly?)

Question 42

Knowledge Check The nurse reviews the care needs for her assigned clients. Which task is inappropriate to assign to the unlicensed assistive personnel (UAP)? a. Make sure the client takes his pills after his meal b. Ambulate a second-day postoperative patient to the bathroom c. Bathe a client who is documented as a fall risk d. Feed a client with a history of embolic stroke

Answer 42

Answer: a

Question 43

? Is the final step of implementation Records the nursing activities and the client's response - How did they tolerate? - Client's view - Do again or was a bad fit? - Included in the medical record

Answer 43

Documentation

Question 44

? Is the final step of the nursing process ? (verb ↑) - Client's progress toward goals - Effectiveness of nursing care plan; identify changes that need to occur - Quality of care in the healthcare setting

Answer 44

Evaluation Evaluate

Question 45

Know that evaluation and assessment are very similar Both involve data collection; the difference is when we're collecting the data and what we're using it for

Answer 45

Assessment --\> collect data to **create** the care plan Evaluation --\> collect data to **revise** the plan of care

Question 46

How Are Standards and Criteria Used in Evaluation? American Nurses Association (ANA) standards include a set of criteria to help describe the standard

Answer 46

Criteria: measurable characteristics, properties, attributes, or qualities Reliable - yield same results every time regardless of who is using it Valid - is measuring what it is intended to measure

Question 47

Types of Evaluation: What is Being Evaluated? Structure Process Outcomes Ongoing Intermittent Terminal

Question 48

? Occurs at the time of discharge

Answer 48

Terminal

Question 49

? Occurs throughout the process

Answer 49

Ongoing

Question 50

? Occurs at specific times

Answer 50

Intermittent

Question 51

? The focus is on setting

Answer 51

Structure

Question 52

? Where we look at observable and measurable changes in client's health status from care that was given

Answer 52

Outcomes

Question 53

? Focus on manner in which care is given

Answer 53

Process

Question 54

How Do I Evaluate Client Progress? Review outcomes (were goals met?) Collect reassessment data (conduct focused assessments based on outcome(s) trying to measure) Judge goal achievement Record evaluative statement Evaluate collaborative problems

Answer 54

Evaluation is not ending the nursing process; it is beginning a new cycle

Question 55

Evaluating and Revising the Care Plan

Answer 55

Relate outcome to interventions (use critical reflection) Draw conclusions about problem status (modify/continue/discard?) Revise the care plan

Question 56

Checklist for Evaluating the Care Plan

Answer 56

Review assessment Review diagnosis (/its definition) Review planning outcomes (review SMART goal components) Review planning interventions Review implementation (get feedback from our client about what went wrong; what could we do better?)

Question 57

Safe, Effective Nursing Care: And What You Can Do as Nurse...

Answer 57

Provide patient-centered and best-practice care Employ best practices for fairness and inclusion Strive to enhance patient satisfaction ratings Ensure compliance with legal and accrediting agency requirements