Nursing Process: Planning Interventions

Front 1

actions based on clinical judgment and nursing knowledge that nurses perform to achieve client outcomes

Back 1

nursing interventions

Front 2

independent nursing interventions

Back 2

-nurses are licensed to prescribe, perform, or delegate based on their knowledge and skills

-does not require a physician order

Front 3

dependent nursing interventions

Back 3

-prescribed by a physician or apn but carried out by the bedside nurse

-requires physician order

Front 4

interdependent (collaborative) nursing intervention

Back 4

-carried out in collaboration with other health team members

Front 5

explain how nursing interventions are determined by problem status (actual vs potential)

Back 5

the status of the problem determines which types of activities are required

actual: to relieve symptoms and resolve etiologies
potential: to remove risk factors in an effort to keep a problem from happening

Front 6

describe the process for generating nursing interventions for a client

Back 6

-use critical thinking skills to select a measure that most likely will achieve the desired goal
-review the nursing diagnosis
-review the desired patient outcomes
-identify several interventions of actions
-choose the best intervention for the patient
-individualize standardized interventions to meet the patient's unique needs

Front 7

Explain how to use a standardized vocabulary for nursing interventions and actions

Back 7

-important for research and clear, precise, and consistent communication among nurses and with other disciplines
-nursing intervention classification (NIC)
-consists of a label, definition, and a list of activities

Front 8

What does a nursing intervention consist of?

Back 8

-label
-definition
-activities nurses perform in carrying out the interventions

Front 9

influence perspective about a situation

Back 9

theory

Front 10

Explain how theory influences your choice of nursing interventions.

Back 10

Theories influence your perspective:

-what you notice
-what you consider to be a problem
-how you define a problem
-what you choose to do about it

Front 11

Describe a five-step process for generating and choosing nursing interventions.

Back 11

1. Review the nursing diagnosis. Nursing orders should flow from the etiology and sometimes from the problem side of the diagnosis.
2. Review the desired patient outcomes. Outcomes suggest nursing strategies that are specific to the individual patient.
3. Identify several interventions/actions that might achieve the desired outcomes for the nursing diagnosis.
4. Choose the best interventions for this patient—those expected to be most effective in helping to achieve client goals.
5. Individualize the standardized interventions to meet the unique needs of the patient.

Front 12

In the NIC system, what is the difference between interventions and activities?

Back 12

● Interventions are broad, general, two- or three-word labels (names); they are the standardized part of the language.
● Activities are the more specific actions the nurse performs in carrying out the intervention; they are not standardized.

Front 13

List the five components of a nursing order.

Back 13

-date
-subject
-action verb
-times and limits
-signature

Front 14

When developing nursing care plans, it is important to remember that nursing orders include which of the following?

A. Outcomes
B. Theories
C. Collaborative problems
D. Strategies

Back 14

D. Strategies

Front 15

List three skills or types of knowledge that nurses need for determining nursing interventions.

Back 15

● Clinical judgment
● Critical thinking
● Past experience

Front 16

Identify five factors that influence the prioritization of nursing problems.

Back 16

● The patient's condition
● New data from reassessment
● Time and resources available for the nursing interventions
● The nurse's level of expertise and experience in assessment and setting priorities
● Feedback from the patient, family, or other healthcare workers

Front 17

Joan R., a 65-year-old woman, was brought to the hospital by her husband. He reported that "she has barely eaten this week, been very quiet, and complains of dizziness, nausea, and a severe headache." Her medical diagnosis includes dehydration. The doctor orders IV fluids at 150 mL/hr. Nursing care includes assessing vital signs every 4 hours, monitoring fluid intake and output, and providing sips of water as tolerated. Interventions to treat her fluid deficit are which of the following?

A. Physician prescribed
B. Nursing prescribed
C. Nurse/client prescribed
D. Collaborative

Back 17

D. Collaborative

Front 18

Joan R., a 65-year-old woman, was brought to the hospital by her husband. He reported that "she has barely eaten this week, been very quiet, and complains of dizziness, nausea, and a severe headache." Her medical diagnosis includes dehydration. The doctor orders IV fluids at 150 mL/hr. Nursing care includes assessing vital signs every 4 hours, monitoring fluid intake and output, and providing sips of water as tolerated.

Which of the following activities is a nurse/physician collaborative intervention for Joan R.? (Assume that all the interventions are appropriate.)
A. Rubbing the patient's back to facilitate relaxation
B. Encouraging the patient to discuss her fears about surgery
C. Assessing the patient's educational needs related to discharge
D. Administering medication to reduce fever and offering Joan up to 500 mL of fluid per shift

Back 18

D. Administering medication and offering fluids

Front 19

A facility is using ___________ nursing care when scientifically sound research data are used to make nursing care decisions.

1) Evidence-based
2) Standardized
3) Individualized
4) Theoretical

Back 19

1) Evidence-based

Front 20

T or F: Nursing interventions are performed for the purpose of assessing health status, preventing and treating illness or disease, and promoting health.

Back 20

True

Front 21

Which of the following is a collaborative intervention?

1) Rubbing patient's back to facilitate relaxation
2) Measuring the patient's blood pressure
3) Assessing the patient's educational needs related to discharge
4) Administering prescribed medications to a patient

Back 21

4) Administering prescribed medications to a patient

Front 22

Which of the following is true of the Nursing Interventions Classification (NIC)? Select all that apply.

1) NIC interventions can be used in all specialty areas of nursing practice.
2) The American Nurses Association (ANA) has approved it for use.
3) It is used mainly by home health nurses.
4) It is designed primarily for use in hospitals.

Back 22

1) NIC interventions can be used in all specialty areas of nursing practice.
2) The American Nurses Association (ANA) has approved it for use.

Front 23

What is wrong with this nursing order? "3/10/2010. Provide measures to relieve anxiety at every patient contact. J. King, R.N."

1) Lacks a target time
2) Does not contain a verb
3) Should not be signed
4) Is vaguely worded

Back 23

4) Is vaguely worded

Front 24

Which nurse is most clearly using evidence-based practice? One who uses an intervention:

1) He read about in a study in a nursing research journal
2) From the agency's critical pathway
3) Published in the clinical practice guidelines of a national group
4) That is individualized to meet a specific patient need

Back 24

3) Published in the clinical practice guidelines of a national group