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39 Cards in this Set

  • Front
  • Back
The purpose of implementation is:
to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning.
During the implementation step, the nurse continues to:
collect data and to modify the plan of care as needed. All activities are documented in the format used by the nurse’s institution or agency.
Nurse case managers are:
specialists in the role of care coordinator.
For actual nursing diagnoses, interventions seek to:
•Reduce or eliminate contributing factors of the diagnosis
•Promote higher-level wellness
•Monitor and evaluate status
For risk nursing diagnoses, interventions seek to:
•Reduce or eliminate risk factors.
•Prevent the problem.
•Monitor and evaluate status.
For possible nursing diagnoses, interventions seek to:
•Collect additional data to rule out or confirm the diagnosis.
For collaborative problems, interventions seek to:
•Monitor for changes in status.
•Manage changes in status with nurse-prescribed and physician-prescribed interventions.
•Evaluate response.
Nurse-initiated interventions,or independent nursing actions,involve:
carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing plan of care, as well as any other actions that nurses initiate without the direction or supervision of another healthcare professional.
Protocols are:
written plans that detail the nursing activities to be executed in specific situations.
standing orders are:
protocols that empower the nurse to initiate actions that ordinarily require the order or supervision of a physician.
Examples include:
admission protocols for obstetric and gynecology patients,
protocols for bowel programs that allow the nurse to select and administer necessary bowel interventions,
standard orders for narcotic overdoses that specify the agents the nurse is to administer to reverse respiratory depression in an emergency, and
standard orders for pain management that enable the nurse to select the strength of the medication to be given within preset ranges.
Physician-initiated interventions,or dependent nursing actions, involve:
carrying out physician-prescribed orders.
State Nurse Practice Acts specify from whom nurses can receive orders.
Nurses are still accountable for dependent orders they implement and are thus responsible for the clarification of any questionable order.
Collaborative interventions,or interdependent nursing actions, are:
those performed jointly by nurses and other members of the healthcare team.
When Implementing the plan of care, nurses use specialized abilities to:
(1) determine the patient’s new or continuing need for nursing assistance,
(2) promote self-care, and
(3) assist the patient to achieve valued health outcomes.
Give nursing interventions the best chance for success by making sure a patient:
is not in too much pain to cooperate, understands what is being attempted and why he or she should cooperate, and
is notdistracted (e.g., by wanting to talk with visitors or watchTV).
If visitors are in the room, check with the patient to see if she or he wants the visitor(s) to stay during the procedure.
If a family caregiver needs to learn new caregiving skills, try to schedule your interventions at a time both appropriate for the patient and convenient for the family caregiver.
Give nursing interventions the best chance for success by making sure the equipment:
Anticipate all the equipment you will need to carry out the intervention and arrange it so that it is easily accessible.
Be sure to order sufficient supplies at the beginning of the shift for the care you expect to provide, and
be thoughtful of the nurse who will follow you by leaving adequate supplies.
Follow agency policy when ordering supplies to ensure proper charges.
To avoid injury on the job, it is essential to take the time to use proper assistive devices,such as lifts for heavy patients or transfer boards for patients with limited mobility.
Give nursing interventions the best chance for success by making sure the environment:
is proper for each intervention.
Pay special attention to respecting the patient’s dignity,
privacy, and
safety needs.
Give nursing interventions the best chance for success by making sure the personnel involved match the intervention's needs:
Identify if you are able to carry out the planned intervention independently or if you are likely to need assistance.
To avoid injury to both patients and professional caregivers, be sure interventions are attempted by the right person or by a sufficient number of people. One helpful tip for teams of student nurses is to begin each rotation by asking, “Who thinks they might need help today?”
The team can then plan to coordinate care so that help is available when needed.
Give nursing interventions the best chance for success by anticipating unexpected outcomes or situations:
The skilled nurse knows what might happen if an intervention “goes wrong”and is prepared to deal with the new challenge. This may be as simple as accurately assessing how much support a patient will need to avoid a fall when ambulating for the first time after surgery.
When implementing nursing care, remember to act in partnership with:
the patient/family.
Before implementing any nursing action, reassess the patient to determine whether the action is:
appropriate and still needed.
When getting ready to implement a nursing action, approach the patient competently and:
Know:
how to perform the nursing action,
why the action is being performed, and be aware of potential adverse responses.

Have all equipment and supplies ready.
When getting ready to implement a nursing action, approach the patient caringly.
Explain the nursing action using language the patient understands.
Communicate genuine concern for what the patient is experiencing.
When getting ready to implement a nursing action, modify nursing interventions according to the patient’s:
(1) developmental and psychosocial background,
(2)ability and willingness to participate in the plan of care,and
(3) responses to previous nursing measures and progress toward goal/outcome achievement.
When getting ready to implement a nursing action,check to make sure that the nursing interventions selected are consistent with:
standards of care and within legal and ethical guides to practice.
When getting ready to implement a nursing action,always question that the nursing intervention selected is the best of all possible alternatives by:
Consulting colleagues and the nursing and related literature to see if other approaches might be more successful.
Evaluate the effectiveness of the intervention selected, noting any factors that positively or negatively influenced the outcome.
When getting ready to implement a nursing action,develop a repertoire of skilled nursing interventions:
The more options one can choose from, the greater the likelihood of success.
Some of the most important patient variables that influence how the plan of care is implemented:
Patient Variables:
the patient is primary in determining how nursing interventions are implemented. Successful nurses modify their nursing actions according to the patient’s:
(1) changing ability and willingness to participate in the plan of care and
(2) previous responses to nursing interventions and progress toward goal/outcome achievement.
(3) developmental stage and
(4)psychosocial background.
Some of the most important patient variables that influence how the plan of care is implemented:
Developmental Stage:
Addressing the developmental needs of a patient involves identifying the patient’s developmental stage, as well as the developmental tasks related to this stage and their relationship to nursing care.
Be careful not to let stereotypes about developmental stages and tasks influence patient care.
To implement a comprehensive and holistic plan of care,nurses must find creative ways to meet developmental needs
Some of the most important patient variables that influence how the plan of care is implemented: Psychosocial needs of patients:
When choosing nursing interventions, the nurse should consider and respect the patient’s socioeconomic background and culture.
Moreover, the nurse needs to assess whether the patient values this intervention and is willing to make the necessary changes.
Some of the most important nurse variables that influence how the plan of care is implemented:
Nurse's abilities
variables that influence the implementation of the plan of care include the nurse's:
levels of expertise,
creativity (ability to match patient needs with specific nursing strategies),
willingness to provide care,
available time, and
ability to think critically about intervention strategies.
Some of the most important nurse variables that influence how the plan of care is implemented:
Resources
The most elaborately designed plan of care cannot be fully effective without adequate staff, equipment, and supplies.
These resources are all important determinants of patient care.
The financial resources of the patient and adequacy of community-based resources also influence the plan of care.
Some of the most important nurse variables that influence how the plan of care is implemented:
Standards of Care
All nursing actions for implementing the plan of care must be consistent with standards of practice. .
All nurses are responsible for learning the standards that dictate practice in their specialty.
Failure to practice according to these standards may result in a charge of negligence.
Some of the most important nurse variables that influence how the plan of care is implemented:
Using Research
Nurses concerned about improving the quality of nursing care use research findings to enhance their nursing practice.
Reading professional nursing journals and attending continuing education workshops and conferences are excellent ways to learn about new nursing strategies that have proved effective.
Some of the most important nurse variables that influence how the plan of care is implemented:
Ethical & Legal Guidelines
To practice good nursing, it is important to be knowledgeable about the laws and regulations that affect healthcare and the ethical dimensions of clinical practice.
An important nursing intervention is ongoing data collection.
In every patient encounter, it is important to be sensitive to both subtle and dramatic changes in the patient’s condition.
Skilled nurses monitor the patient’s responses to planned interventions to determine if the plan of care is working. These assessment findings are used to update and revise the plan of care
Unlicensed Assistive Personnel(UAP) are:
Individuals who are trained to function in an assistive role to the licensed registered nurse (RN) in the provision of patient activities as delegated by and under the supervision of the registered professional nurse.
Delegation is:
the transfer of responsibility for the performance of an activity to another individual while retaining accountability for the outcome.
Never has it been more important for nurses to critically identify which nursing interventions require professional nurses and which can be safely delegated.
The following will help you with the essential responsibilities and techniques of delegating care tasks
:•Know your state and institutional policies on delegation(the policy and procedure manual is available on each unit; for state policies, contact the state nurse association).
•Be clear on the difference between nursing process and nursing tasks.•
Know the training and background of the unlicensed assistive personnel (UAP). (Administration must have a standard and process to validate the UAP’s preparation.)
•Know the patient’s needs and what he or she is at risk for.
•Know what clinical cues the UAP should be alert for and why.
•Assess which tasks can be safely delegated.
•Have the UAP repeat your instructions to be sure you have communicated them clearly.
•Make frequent walking rounds to assess patients.
•When talking with the patient, members of the patient’s family, or UAPs, listen for cues that indicate changes in the patient’s condition.
•Take frequent mini-reports for the UAP.
•Evaluate the UAP’s performance and the patient’s response.
Student nurses may find themselves the recipient of delegated care that they cannot safely perform.
The Student must then:
consult with the instructor to see if you can safely perform it with supervision.
Never attempt to perform interventions beyond your capacity without supervision, even if instructed to do so by a staff nurse. Students who work as nursing assistants are especially likely to be asked to perform interventions beyond their mastery.
You may be able to turn these requests into learning opportunities.
For example, you might say, “I’ve never practiced that procedure but I’d love the opportunity to observe one of the experienced nurses do this.”