Ch 17 implementing

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.

Types of Nursing Interventions

-Those providing direct and indirect care -Those aimed at individuals, family, and community -Those for nurse-initiated and other provider-initiated treatments

Purpose of Implementation

Help the patient achieve valued health outcomes. Promote health. Prevent disease and illness. Restore health. Facilitate coping with altered functioning.

Aims of NOC Research

Identify, label, validate, and classify nursing-sensitive patient outcomes and indicators. Evaluate the validity and usefulness of the classification in clinical field testing. Define and test measurement procedures for the outcomes and indicators.

nurse variables influencing outcome achievement

Resources Current standards of care Research findings Ethical and legal guides to practice

indirect care

Treatments performed away from the patient but on behalf of the patient or group of patients ex. this includes calling for referrals to social work or discussing the need for PT or OT for a patient with doctor

standing orders intervention

a prewritten order that details what the nurse should do in certain situation

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? a.Client with a high fever receiving intravenous fluids, antibiotics and oxygen b.A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall

a. For delegation, the circumstances must be right. The health condition of the client must be stable. The client with a high fever receiving intravenous fluids, antibiotics, and oxygen is the least stable

Alfaro's Rule

assess, reassess, revise, record

The surgeon is insisting that a client consent to a hysterectomy. The client says that she will not make a decision without her husband's consent. What is the nurse's best course of action? a.Ask the client if she is afraid that her husband will be angry. b. Ask the surgeon to wait until the client has had a chance to talk to her husband.

b

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? a. The client who needs vital signs taken following infusion of packed red blood cells. b. The client with continuous pulse oximetry who requires pharyngeal suctioning.

b. The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to evaluate the client's response in pulse oximetry to the suctioning.

Independent interventions

can be accomplished without a doctors order, protocol or standing order

patient variables influencing outcome achievement

development stage psycho social background and culture

common reason for noncompliance

lack of family support lack of understanding about the benefits low value attached to outcomes adverse physical or emotional effects of treatment inability to afford treatment limited access to treatment

the nursing intervention taxonomy

nursing interventions classifications labels definition set of activities for intervention nursing outcomes classifications

advantage of using nursing intervention

reimbursement

collaborative interventions

requires a doctor's order, protocol or standing order may require working with other interpersonal team members

Five Rights of Delegation

right task right circumstance right person right direction/communication right supervision/evaluation

protocols intervention

written plans that detail the nursing activities done in certain situation

Implementing Guidelines

• Act in partnership with the patient/family. • Before implementing, reassess the patient to determine whether the action is still needed. • Approach the patient competently. • Approach the patient caringly. • 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.

The nurse assigned to care for a client that has received a sedative has asked the unlicensed assistive personnel (UAP) to help the client to the toilet. The nurse demonstrates proper delegation skills by performing which actions? (Select all that apply.) 1. giving a report on the client to the UAP and answering questions 2. being available for questions from the UAP 3. transferring accountability and responsibility for the client to the UAP 4. confirming the UAP has successfully passed this skill competency 5. confirming that the UAP has repeatedly completed similar tasks

1,2,4,5

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action? a.Go to the client and assess the client's pain. b.Determine the frequency of pain medication.

a. The nurse's first action should always be to determine the cause of the client's pain in order to determine the correct intervention.

intervention

any treatment based upon clinical judgement and knowledge that a nurse performs to enhance patient/client outcomes

Reassessing the Patient and Reviewing the Plan of Care

be sure each nursing intervention is supported by a sound scientific rationale, as demanded by evidence-based practiced be sure that each nursing invention is consistent with professional standards of care and consistent with protocols, policy, and procedures of institution or agency be sure nursing action is safe for this particular patient and individualized to patient preferences clarify any questionable orders

Checklist for Organizing Student Clinical Responsibilities

patient profile and name by which patient is addressed patient chief compliant and reason for admissions patients current health status routine assistance to meet basic human needs priorities for nursing care and special daily event special teaching, counseling or advocacy needs special family needs

care coordination and critical thinking/clinical reasoning and implementing

reassess the patient for changes in status that might dictate a different set of interventions be sure the research support the intervention you have selected and be open better way of addressing patient problem and issues always monitor the patient responses to your interventions so that you can modify the care plan if needed

implementing care plan

reassessing- reassessing the patient and reviewing the care plan clarifying- clarifying prerequisites nursing competencies organization- organizing resources (having all supplies) anticipating- anticipating unexpected outcome/situations (having extra supplies) preventing- preventing errors and omissions promoting- promoting self-care: teaching, counseling, and advocacy assisting- assisting patients to meet outcomes

direct care

treatments performed through interactions with patients