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41 Cards in this Set

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Def. of inplementation and nursing intervention is on pp 340 Potter.

what is implementation?
(where nurses provide care to pts)
Implementation is the step of the nursing process where nurses provide care to patients. The nurse initiates (gives orders to cna or lpn) & completes actions or interventions necessary for acheiving goals and expected outcomes of nursing care.
what is a nursing intervention?
any treatment, based on clinical judgement and knowledge, that a nurse performs to enhance client outcomes. Interventions include both direct and indirect care, families, patient, communities
what are some examples of direct care interventions?
starting an IV
telling a cna to bath pt
counseling family of diabetes
evaluating staff
recording documentation
performing a task
What is indirect intervention?
treatments performed away form the client but in their behalh
Ex. safety and infection control, or documentation, etc
what is the main part of implementation?
Implementation is the 4 step of the nursing process. what were the first three?
client centered goal
nurse iniated actions
client hasnt voided in 8 hours
achieve emptying bladder (11/18) as evidence by:
Urine output greater tan 240 mL during single voiding
Now the implementatin:
insert straight catheter, using sterile technique, if client has not voided in 8 hours and bladder is palpable
Evaluation (outcome) 1000 mL of clear yellow urine is returned via straight catheter (11/19)
The whole nursing process is a continuing process, we are continuing assessing and implementation continues too. Not only in delegating but also teaching, performing the task, etc. So implementation involves all these things. including ...
The focus is the initiation of interventions, the achievement of GOALS
And immplementatin is about either directly doing stuff or delegating that care work, but there's more than delegation. But who can delegate?
MDs, LPNs, etc all delegate.
while we do implementation, we as nurses are always, ...
modifying care plan
rewrtiting goals if necessary
But we MUST make sure by reassessing nothing has changed!
a protocol is a written plan about some procedure to follow. Like for a pt and some condition or situation. all kinds. What are some examples?
starting CPR
pain management
admission & discharge
diagnostic tests
physical/speech/occupational therapy
What is a standing order?
a preprinted document, orders for therapy EXs:
routine therapy
monitoring guidelines
diagnostic procedures
These orders direct the conduct of care for a pt in the clinical setting. Must be approved by MD, b/f doing them
What are EX of standing orders?
CCU setting, standing orders for:
specific meds given for pain
something for irregular heart
The Charge nurse doesn' have to call anyone, just take care of it.
So a standing order is signed by someone and allows the delegated one to take it from there, or implement it ...
gives nurse legal protection to intervene quickly in client's best intrest
what is the definition of delegation
transfer of responsiblity of performance of ans acitivity while retaining accountability
ANA, 1995
another definition of delegation by the SCSBN 1997
transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains accountability for the delegation.
the key terms in both definitions are:
selected tasks
selected situations
Critical thinking time

a job to be delegated. should that person get that job just because they're checked off on it?
someone who hasn't done something in a long time shouldn't be given the delegated job!
Before doing an implementation, 5 prep activities are needed. What are they?
reassessing the patient
(a continual process)

reviewing/revising care plan
(does current data relate to latest assessment?)

organize resources/care delivery
(eqiupment, people, enviroment, client) get ready

Anticipate complications!
(know in advance where help is)

Inplementing skills
(cognitive, interpersonal, phycomotor ((how a syringe is used)) do Tx safely)
The delegate is accountable for accepting the delegation and for their action carrying out the task

when nurse delegates wrongly
when nurse supervises wrongly
there are 4 rights of delegaton
right task
right person
what else?
right communication
right evaluation/feedback
right circumstance
Again what are the 4 rights of delegation again?
right task
riight person
right communication (4 C's)
evaluation/feedback (pt remarks) (discuss the job, not personality stuff)
the 4 c's are about the right communication.
Clear, Concise, Correct, Complete, these are the way to communicate. say them again
this is how you tell someone what to do. clear,concise,correct,complete
the right circumstance is about what?
is about when should you delegate
is the patient stable?
task is w/in their job descripton
when the amt of time the RN is reduced.
Don't delegate when:
its complex assignment
complex judgements required
when there is an increase risk of harm
what else
when problem solving and creativity is required
so would you delegate a task for a instable patient?
hell no,,,test question
what does ADLs mean?

Hint: Its a Direct Care Measure
Activities of Daily Living


what is performed usually daily, like what CNAs do...its delegated tasks!
There can be ADLs with acute and long term care!
what is a protocol?
a protocol is a plan that we don't need an order for, its PRE Written so its INDEPENDENT
Ex. a fire drill
Don't need an order for this
so there are also orders already written out to save time called

standing orders

what are these
already written out that a nurse can do without any more hassling a doctor. Ex. of a standing order:

who is bc oc?
bowel care of choice
so the nurse can go to this standing order w/o calling the physician.
a specialist MD might say on the first day remove the catherter at first am. So this is a standing order, its already written up. There are 2 things important to the standing order. It gives the nurse legal protection to provide care and . . .
to allow nurse to do work in the best intrest of the patient.
Know Standing Order
more about delegation. Huge thing:
ANA def
NCSBN def.
what is the reason for these?
to protect the nurse
to protect the patient
"a transfer of responsibility of performance while retaining accountability
another def of delegate?
transfer to a competent ind. the authority to perform a selected task in a selected situation.
Nurse retains accountability for the delegation.
what are the 4 rights of delegation? t p c e
right task
right person
right communication
right evaluation
the right task. we ask the right question. is it within the scope of the person's basic education program? substitute any level into the equation/ the scope of practice to find out what?
if they are competent to do the task. This doesn't mean that they they can do something they haven't done for 5 years!
In order to delegate properly, the nurse must know:
the state nurse practice act
the state nursing standands
facility policies & procedures
the worker's capabilities/limitations
and the 4 what?
the 4 rights of delegation...
right task
right person
right communication
right evaluation/feedback
the 2 right of delegation is person and what this is really about is if this person if competent to do something. How do you know this?
job description
skills checklist
demonstrated skill
the 3 right of delegation is the right communication. the 4 c's means what?
use the 4 c's to communicate!
the last 4th right is the right evaluation/feedback. who's feedback is this usually?
the patients feedback!
was it timely
the worker's performance
ask for workers input
discuss issues, not personalities
these's common sense here too:
the delegation should be when the patient is:
task is w/in worker's job description
and the biggy is ...
the amt of time the RN is or will have to spend w/ pt isn't reduced.
when do you not delegate?
when its a complex assignment
when outcome is unpredictable
a possible increase of harm
when problem solving & creativity is required
so in conclusion to delegate you must look at the big picture, the whole circumstance, including family, everything. Review, are the 4 rights in place?
what are these again?
right task
right person
right communication(4 c's)
right evaluation/feedback
these things must be in place for the nurse to perform good supervision, consider the setting and situation.