Sherpath 19: Take Action

Question 1

take action is which step of CJMM

Answer 1

fifth step: This step is essential to achieving positive patient outcomes and promoting optimal health and wellness for the individualized plan of care

Question 2

types of interventions are

Answer 2

Direct (contact with patients) or indirect (without patient interaction)

Nurse-initiated, health care provider–initiated, or other provider–initiated (interprofessional health care team member)

Independent (does not require collaboration or a health care provider prescription), dependent (requires a prescription from a health care provider), or collaborative (requires teamwork among the interprofessional health care team)

Evidence-based practice (aligned with the most current, scientifically supported care measures)

Question 2

To determine which actions to take, the nurse will

Answer 2

-Consider which intervention or combination of interventions is most pertinent for the patient and supports the achievement of established goals and outcomes.
-Contemplate the best way to perform the interventions, considering the unique circumstances and conditions of the individual patient’s scenario.

Question 3

Previous steps of the CJMM concentrated on the following

Answer 3

Step 1: Recognizing cues, which meant identifying what was most important among the patient cues collected during the assessment.

Step 2: Analyzing cues, which meant considering what those cues could potentially mean by identifying potential or actual patient problems, known as hypotheses.

Step 3: Prioritizing hypotheses, which meant determining where the nurse should focus efforts by ranking the hypotheses so the most serious patient needs could be addressed first.

Step 4: Generating solutions, which meant considering what the nurse could do by connecting patient needs to a plan of care, determining outcomes and possible interventions.

In the fifth step, take action, the nurse will now consider which actions are the most appropriate.

Question 4

Critical practice guidelines (CPGs) are

Answer 4

recommendations facilitating the application of current evidence into nursing practice to optimize patient care. They are based on a systematic review and critical analysis of literature related to a health care problem or clinical situation, including the potential benefits and harms of different interventions.

Question 5

care bundle is a

Answer 5

set of three to five evidence-based interventions that improve patient care outcomes when performed collectively and consistently.

Question 6

A standing order is a

Answer 6

preestablished set of health care provider orders (routine therapies, monitoring guidelines, or diagnostic procedures) used to direct patient care in clearly defined circumstances. It is used commonly in critical care or other acute care settings where a patient’s condition might change rapidly, requiring immediate attention.

Question 7

American Nurses Association (ANA) Scope and Standards of Practice outline the

Answer 7

duties that all nurses should be able to perform competently, irrespective of role, setting, or specialty (ANA, n.d.).

Examples:
Optimization of health
Prevention of illness and injury
Facilitation of healing
Alleviation of suffering
Patient advocacy

Question 8

factors influencing actions

Answer 8

knowledge
experience
attitudes
standards of care
interprofessional relationships

Question 9

Context refers to

Answer 9

aspects that influence the understanding of an event, circumstance, or condition.

Question 10

urgent vs non-urgent

Answer 10

urgent: ABC is compromised

non-urgent:
Time-sensitive actions
Actions that others can perform
Interventions that treat more than one problem
Interventions requiring action before they can occur

Question 11

as the nurse determines which actions to take, the nurse should

Answer 11

1. Reassess the patient.
2. Revise the plan of care based on collected patient cues if needed.
3. Anticipate complications.

Question 12

Nurses should do the following when determining how to take action to address prioritized needs

Answer 12

Review all possible nursing interventions for the patient problem.

Incorporate professional and organizational standards of clinical practice.

Recognize which interventions are needed immediately.

Consider all potential consequences associated with each possible nursing action.

Determine the probability of potential consequences.
Judge the value of the consequences to the individual patient.

Collaborate with the interprofessional health care team.

Consider which interventions can be delegated and to whom.