Fundamentals Of Nursing Chapter 9

Front 1

Implementation

Back 1

Consists of performing a task and documentation of each intervention

Front 2

Direct care

Back 2

refers to interventions that are carried out by having personal contact with patients

Front 3

Indirect care

Back 3

includes nursing interventions that are performed to benefit the patients but do not involve face to face contact with patients

Front 4

Independent Nursing Interventions

Back 4

Are tasks within a nursing scope of practice that the nurse may undertake without physician or PCP order

Front 5

Dependent Nursing Interventions

Back 5

are tasks the nurse undertakes that are within the nursing scope of practice but require the order of a primary health care provider to be implemented. They require nurses to pay close attention to the details of what is ordered and to recognize when implementing is appropriate or should be withheld.

Front 6

Standing orders

Back 6

Orders that are received through a pre approved standardized order set

Front 7

Evaluation

Back 7

focuses on the patient and the patient's response to nursing interventions an outcome attainment

Front 8

significance of implementation and evaluation in the nursing process

Back 8

Nurses and other members of the interdisciplinary health care team provide care through interventions designed to promote, maintain, or restore a patient's health during the implementation phase. Implementation consists of performing task and documenting each intervention. Evaluation focuses on the patient and the patient's response to nursing interventions and outcome attainment. Evaluation data are used by the nurse to adapt a plan of care on the basis of the patient's changing health status

Front 9

Different types of direct care interventions

Back 9

refers to interventions that are carried out by having personal contact with the patient. Include reassessing patients, assisting with ADLs, giving physical care, counseling and teaching

Front 10

Different forms of indirect care interventions

Back 10

Includes interventions performed to benefit the patients without face to face contact. Include communicating and collaborating with other health care team members, making referrals, doing research, advocating, delegating, and engaging in preventative actions such as patient education and health promotion

Front 11

examples of independent nursing

Back 11

interventions are tasks that are within the nursing scope of practice that the nurse may undertake without a physician or PCP order. Often determined by the area in which care is taking place.

Front 12

Recognizing dependent nursing interventions

Back 12

tasks that the nurse undertakes that are within the nursing scope of practice but require an order from the MD or PCP to implement. They require nurses to pay strict attention to what was ordered and to recognize when implementation is appropriate or should be withheld

Front 13

Significance of documenting the implementation step

Back 13

Nurses must document effectively to convey information accurately to other health care providers. Within the HIPAA guidelines, patient documentation is provided to the insurance companies and others for billing and reimbursement

Front 14

Apply evaluation principles in the nursing process

Back 14

focuses on the patient and the patient's response to the interventions and outcome attainment. not a record of care that was implemented. Information on the effectiveness of nursing interventions is a by product of the process. Nurses use critical thinking skills to determine whether a patient's short term and long term goals were met and the desired outcomes were achieved.

Front 15

Describe the relationship between the nursing care plan modification and quality improvement

Back 15

modifications are based on the effectiveness of interventions to meet and improve desired patent outcomes. QI processes benefit patients and ultimately affect patient care. If certain patient outcomes are consistently improved by the implementation of specific nursing interventions, procedures can be changed on the basis of the QI research

Front 16

Rights of Medication Administration

Back 16

Nurses check the PCP's orders, the patient's allergies, and the expiration date of the medication to be administered. The 6 rights include:

1. administering to the right patient

2. administering the correct dosage

3. Administering to the correct route

4. The right medication

5. the right time

6. documenting correctly

Front 17

Standing orders for patients with chest pain

Back 17

- Assess vital signs

- Obtain an ECG

- Initiate or maintain telemetry

- Initiate oxygen therapy beginning at 2L NC, monitor pulse oximetry levels

- Administer sublingual nitroglycerine (0.4 mg SL); repeat up to three times, as needed

- Initiate intravenous access, if not already available

- Notify lab to asses cardiac enzymes

- Notify physician for further orders

Front 18

Steps of implementation

Back 18

Interventions:

- Independent

- dependent

- collaborative

Care

- Direct

-Indirect

Documentation

- NIC

Care plans

- clinical pathways

- Protocols

- Standing orders

Front 19

Steps of Evaluation

Back 19

Care plan Evaluation

- Patient goal/outcome attainment?

- continue?

- revise/adapt?

- discontinue?

Front 20

Evaluation statement when goal is MET

Back 20

Goal met. patient consistently requests assistance before toiling. Continue plan of care to ensure patient safety, or discontinue plan of care because patient no longer requires assistance for safe use of toilet

Front 21

Evaluation statement when goal is PARTIALLY MET

Back 21

Goal Partially met. Patient forgetting to ask for assistance with toiling during the day. Revise plan of care to include use of bed alarm

Front 22

Evaluation statement when goal is UNMET

Back 22

Goal is unmet. Discontinue plan of care. Patient is no longer able to call for assistance due to diminished level of consciousness.