Chapter 6 Implementation and evaluation

A nursing audit must:

Occur in every hospital to maintain accreditation.

Nursing audit

The examination of a series of patient records to determine whether nursing care for those patients met particular standards and particular outcomes.

Clinical Pathway or care map

A step by step approach to the total care of the patient. Also called: 1) Interdisciplinary care plan 2) Collaborative care plan

Before carrying out a specific intervention in the patient plan of care, a nurse should: (Select all that apply.) A) Identify the reason for the intervention. B) Identify the rationale for the intervention. C) Identify the usual standard of care. D) Identify any potential dangers.

A) Identify the reason for the intervention. B) Identify the rationale for the intervention. C) Identify the usual standard of care. D) Identify any potential dangers.

Revision of the nursing care plan

A) Inactivating resolved problems.

Interdependent action

Actions that come from collaborative care planning. Example: Assisting the speech therapist by helping the patient practice speech exercises.

Dependent nursing action

Administering a medication because it requires a primary care provider's order. Example: Ordering a heating pad and applying it to a patient.

__________ is judgment of the effectiveness of the intervention or plan and is a collaborative process.

Evaluation

Which is an independent nursing action? A) Administering medication B) Giving a back massage C) Ordering a heating pad and applying it to a patient D) Assisting a physical therapist by helping a patient with exercises

B) Giving a back massage

In which step of the nursing process are nursing interventions carried out? A) Nursing diagnosis B) Planning C) Implementation D) Evaluation

C) Implementation

Time - flexible

Can be done any time

Independent nursing action

Does not require a primary care provider's order but it does require critical thinking and critical judgement. Example: Giving a back massage

Implementation

Giving care

Quality improvement

Identify specific areas that need changes. This is the units responsibility Therefore, nurses on a unit usually rotate as the quality management person for the unit to involve everyone in the process.

The goal of an outcome-based quality improvement (OBQI) program is

Improve nursing practice.

Outcome - based quality improvement ( OBQI )

Improvement of the quality of performance programs and are used to evaluate nursing care delivered to patients.

Time fixed

Must be done at a set time

Interventions

Nursing orders ( actions )

Which statement is true regarding construction and utilization of nursing care

Nursing students use nursing care plans for their assigned patients.

Document

To record/ the recording of pertinent data on the clinical record.

Documentation

To record/ the recording of pertinent data on the clinical record.

Care plans are not part of the patient's chart when an interdisciplinary care plan is used. True or false

True, however, the nursing process is still used

If the expected outcomes considered met, the nurses documentation must contain:

data to support this