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NUR 101 Assessment #3 > Nursing Process III > Flashcards

Nursing Process III Flashcards

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1
Q

Nursing Process III

A

Interventions
Implementation
Evaluation

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2
Q

Nursing Process: Planning Interventions

To achieve planned outcome(s)

A
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3
Q

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
A
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4
Q

?

Is care away from the client; acting on their behalf

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

A

Indirect care

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5
Q

?

Is care given directly to the client

i.e. administering a medication

A

Direct care

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6
Q

Types of Nursing Interventions

A

Independent

Dependent

Interdependent

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7
Q

?

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

A

Interdependent

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8
Q

?

The nurse is accountable for

NOT provider prescription orders

Nurse prescribes and performs these interventions in response to nursing diagnosis

A

Independent

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9
Q

?

Is something prescribed by the provider and implemented by the nurse

A

Dependent

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10
Q

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

A

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)

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11
Q

Choosing Nursing Interventions

Use

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

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
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12
Q

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
A
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13
Q

?

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

A

Impact

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14
Q

?

Term that refers to how useful the data is

A

Applicability

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15
Q

?

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

A

Validity

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16
Q

Types of Research-Based Support

A

Single studies

Systematic reviews and meta-analysis

Clinical pathways and protocols

Evidence reports

Clinical practice guidelines

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17
Q

?

These form the basis of nursing interventions

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

A

Clinical practice guidelines

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18
Q

?

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

A

Clinical pathways and protocols

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19
Q

?

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

A

Evidence reports

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20
Q

?

Are found in nursing journals

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

A

Single studies

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21
Q

?

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

A

Systematic reviews and meta-analysis

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22
Q

How does problem status influence nursing interventions?

A

Actual nursing diagnosis

Potential nursing diagnosis

Possible nursing diagnosis

Collaborative problem

Wellness diagnosis

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23
Q

?

These are interventions that focus on optimal well-being

A

Wellness diagnosis

24
Q

?

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

A

Potential nursing diagnosis

25
Q

?

Where there is an actual problem

Change in client status; interventions are based on restoring client health

A

Actual nursing diagnosis

26
Q

?

These terms are interchangeable

Are in conjunction with another member of the healthcare team (i.e. physicians)

A

Possible nursing diagnosis & collaborative problem

27
Q

Process Used for Generating and Selecting Interventions

A
28
Q

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
A

Standardized Language for Interventions cont’d

The Clinical Care Classification

The Omaha System

29
Q

?

Involves standardized language used in community healthcare

A

The Omaha System

30
Q

?

Involves standardized language used in home healthcare

A

The Clinical Care Classification

31
Q

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

A

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
32
Q

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
A

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
33
Q

Nursing Process: Implementation and Evaluation

A
34
Q

What 3 items are involved in the implementation phase?

A

Doing

Delegating

Documenting

35
Q

Preparing for Implementation

A

Check your knowledge and abilities

Organize your work

* Establish feedback points

* Prepare supplies and equipment

Prepare the client

36
Q

Check your knowledge and abilities

A
  • Clarify orders
  • Are we qualified/authorized to carry out the intervention?
  • Is the action safe, reasonable, and prudent?
37
Q

Organize your work

A
  • What interventions can be done simultaneously?
38
Q

Prepare the client

A
  • 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
39
Q

Implementing the Plan

A

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

40
Q

Delegation and Supervision

Transferring responsibility while retaining accountability

Includes supervision (of UAP, LPN/LVN)

A

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

41
Q

What are the 5 rights of delegation?

A

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?)

42
Q

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

A

Answer: a

43
Q

?

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
A

Documentation

44
Q

?

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
A

Evaluation

Evaluate

45
Q

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

A

Assessment –> collect data to create the care plan

Evaluation –> collect data to revise the plan of care

46
Q

How Are Standards and Criteria Used in Evaluation?

American Nurses Association (ANA) standards include a set of criteria to help describe the standard

A

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

47
Q

Types of Evaluation: What is Being Evaluated?

Structure

Process

Outcomes

Ongoing

Intermittent

Terminal

A
48
Q

?

Occurs at the time of discharge

A

Terminal

49
Q

?

Occurs throughout the process

A

Ongoing

50
Q

?

Occurs at specific times

A

Intermittent

51
Q

?

The focus is on setting

A

Structure

52
Q

?

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

A

Outcomes

53
Q

?

Focus on manner in which care is given

A

Process

54
Q

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

A

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

55
Q

Evaluating and Revising the Care Plan

A

Relate outcome to interventions (use critical reflection)

Draw conclusions about problem status (modify/continue/discard?)

Revise the care plan

56
Q

Checklist for Evaluating the Care Plan

A

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?)

57
Q

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

A

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

NUR 101 Assessment #3 (11 decks)

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