Chapter 19: Implementing Nursing Care

Question 1

Implementation begins after

Answer 1

the development of the Plan of Care.

Question 2

Implementation includes

Answer 2

interventions designed to achieve goals and expected outcomes to support or improve the patient’s health status

Question 3

Nursing Interventions

Answer 3

any rx based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes.

Question 4

Nursing interventions are

Answer 4

• evidence-based
• most up-to-date and effective approaches
• includes direct and indirect care measures

Question 5

Direct Care Measures

Answer 5

-performed by directed interactions with patients.

Question 6

Indirect Care Measures

Answer 6

-treatments performed away from the patient but on behalf of the patient

Question 7

Direct Care Measures include

Answer 7

• medication administration
• insertion of an IV infusion
• counseling.

Question 8

Indirect Care Measures include

Answer 8

• documentation
• interdisciplinary collaboration
• order entry
• managing safety and infection control measures

Question 9

What are the intervention categories?

Answer 9

1. independent
2. dependent
3. collaborative

Question 10

independent interventions

Answer 10

patient teaching, monitoring therapeutic interventions

Question 11

dependent interventions

Answer 11

MD orders

Question 12

collaborative interventions

Answer 12

consultations, interdisciplinary conferences

Question 13

Tips for Making Decisions: Implementation

Answer 13

1. Review the set of all possible nursing interventions for the patient’s problem. (pain-positioning, pharmacology, relaxation techniques)
2. Review all possible consequences associated with each possible nursing action. (each intervention may work, not work or cause adverse reactions)
3. Determine the probability of all possible consequences. (pain medication has worked in the past with no adverse reactions - unlikely adverse reactions will occur)
4. Make a judgement of the value of the consequence to the patient. (if the patient has a decreased pain level he/she will be less anxious and more receptive to therapeutic interventions (moving, instructions)

Question 14

When you proceed with an intervention, consider:

Answer 14

• what you know about the intervention
• the steps in performing the intervention correctly
• the medical condition of the patient
• his/her expected response
• know the clinical standards of practice for your agency

Question 15

With interventions, apply:

Answer 15

intellectual standards and critical thinking attitudes

Question 16

Intellectual standards

Answer 16

relevant, clear, logical and complete

Question 17

critical thinking attitudes

Answer 17

confidence (builds pt trust), creativity (reviewing & modifying interventions) and self-discipline (seek supervision as guide in the decision making process)

Question 18

standardized interventions

Answer 18

make it quicker and easier of a nurse to intervene

Question 19

standardized interventions are used in the form of:

Answer 19

• clinical guidelines
• protocols
• preprinted (standing) orders
• nursing intervention classification (NIC) interventions
• ANA Standards of Professional Nursing Practice- includes standards for the implementing step of the nursing process.

Question 20

Clinical Guidelines/Protocols

Answer 20

• interventions for a specific health care problem or condition.
• seen as key tools for improving the quality of health.

Question 21

Clinical Guidelines/Protocols are developed from

Answer 21

scientific literature and standard of practice

ex) rapid assessment protocols (stroke, STEMI), fall prevention, DVT, pressure ulcer, incontinence management, admission & discharge procedures.

Question 22

Standing orders

Answer 22

a preprinted document (MD orders) containing conduct of routine therapies, monitoring guidelines, diagnostic procedures for a specific patient population.

Question 23

Standing orders give the nurse

Answer 23

legal protection to intervene appropriately in the patient’s best interest.

ex) pt presenting to the ED w/ CP, abd pain and ortho c/o; critical care settings: pts w/ life threatening arrhythmias, BP

Question 24

Nursing interventions classification (NIC)

Answer 24

• common interventions recommended for various NANDA nursing diagnoses.
• developed by University of Iowa: helps to differentiate nursing practice from other healthcare professionals.
• standardization to enhance communication of nursing care across settings and to compare outcomes.

Question 25

ANA Standards of Professional Nursing Practice

Answer 25

The standard of care that registered nurses provide their patients

Question 26

The standards of care that registered nurses provide include

Answer 26

- competencies for establishing professional and caring relationships - using evidence-based interventions and technologies - providing holistic care across the lifespan to diverse groups - using community resources and systems - implementing a timely plan following patient safety goals

Question 27

QSEN

Answer 27

- Quality and Safety Education for Nurses | - Knowledge, Skills, Attitudes

Question 28

Five Preparatory Activities:

Answer 28

1. reassessing the patient 2. review and revise the existing nursing care plan 3. prepare for implementation 4. anticipating and preventing complications 5. implementation nursing interventions (cognitive, interpersonal, psychomotor)

Question 29

Preparing for Implementation

Answer 29

- equipment: working, know how to use, availability - time management - personnel: delegation duties, collaborative - environment: patient assist devices, lighting, safe environment - patient: physical (toileting) and psychological comfort, level of endurance

Question 30

Anticipating and Preventing Complications

Answer 30

- risks come from both illness and treatment | - evaluate benefit vs risk and take risk-prevention measures

Question 31

Identifying Areas of Assistance

Answer 31

- do not hesitate to obtain assistance by seeking additional personnel, knowledge, and/or nursing skills - do not take shortcuts if assistance is not immediately available: increases risk of injury to you and the patient.

Question 32

When administering new medications, operating a new piece of equipment, or performing an unfamiliar procedure:

Answer 32

- review hospital policy and procedure - collect all equipment necessary - have another nurse/instructor provide assistance and guidance

Question 33

Implementation Skills:

Answer 33

1. cognitive skills 2. interpersonal skills 3. psychomotor skills

Question 34

Cognitive skills

Answer 34

application of critical thinking in the nursing process: - know the rationale for the therapeutic intervention - know the normal and abnormal physical and psychological responses

Question 35

Interpersonal Skills

Answer 35

Communication is critical. - keep pts informed - provide individualized pt teaching - support pts emotional needs - be perceptive of the pts verbal and nonverbal communication

Question 36

Psychomotor Skills

Answer 36

cognitive and motor activities. | -good coordination and precision to perform a skill correctly.

Question 37

Activities of Daily Living (ADLs)

Answer 37

- ambulation, grooming, bathing. | - is the pts need for assistance w/ ADLs temporary, permanent or rehabilitative?

Question 38

Instrumental Activities of Daily Living (IADLs)

Answer 38

- shopping, preparing meals, house cleaning, writing checks, taking medications. - home health nurses, occupational health therapists

Question 39

Physical Care Techniques

Answer 39

safe patient handling, infection control practices, stay organized follow practice guidelines

Question 40

Lifesaving Measures

Answer 40

emergency medications, resuscitation, intervening to protect a confused or violent patient

Question 41

Counseling

Answer 41

- emotional, intellectual, spiritual, and psychological support to the pt and family. - assess family caregivers for caregiver role strain and the possible need for respite (a break from providing care)

Question 42

Teaching

Answer 42

- education key to patient-centered care - focus on intellectual growth, acquisition of new knowledge or psychomotor skills - know your patients health literacy level

Question 43

Controlling for Adverse Reactions

Answer 43

- potential to follow any nursing intervention: medication administration, diagnostic test. - anticipate and know which adverse reactions to expect.

Question 44

Preventative Measures

Answer 44

1. primary prevention 2. secondary prevention 3. tertiary prevention

Question 45

primary prevention

Answer 45

health promotion including health education programs, immunizations and physical and nutritional fitness activities.

Question 46

secondary prevention

Answer 46

- focuses on those who are experiencing health problems or illness and who are at risk for developing complications or worsening conditions. - includes screening techniques and treating early stages of disease.

Question 47

tertiary prevention

Answer 47

involves minimizing the effect of long-term illness or disability, including rehabilitation measures.

Question 48

Indirect care can also

Answer 48

- support direct care interventions - change of shift report - may be managerial in nature: emergency cart maintenance, supply management - consultation of interdisciplinary care plans - delegation of care to CNA or NAP

Question 49

Achieve Patient goals

Answer 49

- introduce interventions that patients are willing and able to follow. - apply principles of care coordinations.

Question 50

Principles of care coordinations include

Answer 50

- good time management - organizational skills - appropriate use of resources to ensure you deliver interventions effectively and meet desired outcomes. - priority setting