NUR304 - Adult Health - Exam 2 Study Guide - Nursing Process: Planning Interventions
Understand critical pathways, clinical practice guidelines and evidenced reports
*Critical pathways* (also called clinical pathways and collaborative care plans) are standardized plans of care for frequently occurring conditions (e.g., total hip replacement) for which similar outcomes and interventions are appropriate for all patients who have the condition. They are tools developed by an organization for its own use and are intended to guide best practice at the local level. However, they may not be based on research if the practitioners who develop them are reluctant to change traditional practices they believe to be effective. Furthermore, issues of cost to the organization infl uence the decision to include an intervention in the plan of care. Nevertheless, critical pathways provide a guide for nursing interventions in that, at the very least, they have been developed on the basis of expert opinion. *Evidence reports* are state-of-the-art, systematic reviews of clinical topics for the purpose of providing evidence for practice guidelines, quality improvement, quality measures, and insurance coverage decisions (Cronenwett, 2002). Evidence reports are usually developed by scientists rather than clinicians, patients, and advocacy groups. Two sources of such reports are (1) the Registered Nurses' Association of Ontario, Canada and (2) the Evidence-Based Practice Center (EPC) Program of the federal Agency for Healthcare Research and Quality (AHRQ). The EPC uses explicit grading systems to review studies and rank the strength of their evidence. Evidence reports often form the basis for developing clinical practice guidelines. *Clinical practice guidelines* are systematically developed statements to assist practitioners and patients in making decisions about appropriate healthcare for a particular disease or procedure (Institute of Medicine, 1992). Clinical practice guidelines are usually developed by clinicians, patients, and advocacy groups and are published by specialty organizations, universities, and government agencies.
Understand the differences between indirect-care and direct care intervention
*Nursing interventions* are actions, based on clinical judgment and nursing knowledge, that nurses perform to achieve client outcomes. Interventions are also referred to as nursing actions, measures, strategies, and activities. A *direct-care intervention* is one performed through interaction with the client(s). Direct-care activities include physical care, emotional support, and patient teaching. An *indirect care intervention* is performed away from the client but on behalf of a client or group of clients. Indirect care activities include advocacy, managing the environment, consulting with other members of the healthcare team, and making referrals.
based on their knowledge and skills.
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form: (1) in response to nursing diagnoses and (2) for
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physical care, and environmental management.
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teaching, counseling and emotional support, referral,
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the purpose of achieving client outcomes.
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treatments—those that nurses perform or delegate
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➤ Ideally, a nursing intervention should have a sound basis in research.
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➤ Independent interventions are nurse-initiated
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➤ Nursing interventions are treatments that nurses per-
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➤ Nursing interventions include such activities as
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➤ Nursing orders, written on the nursing care plan, consist of the detailed instructions for performing nursing interventions.
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➤ Standardized vocabularies are especially useful in agencies that have computerized care planning systems.
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➤ Standardized vocabularies include terminology for describing wellness interventions and spiritual interventions.
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➤ The American Nurses Association has approved the following three standardized vocabularies for nursing interventions: (1) the Nursing Interventions Classification (NIC), (2) the Omaha System (developed for community health nursing), and (3) the Clinical Care Classification (CCC).
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➤ Theories influence your perspective: What you notice and identify as a problem, as well as how you define a problem, more or less determines your choice of interventions.
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➤ When generating interventions, nurses use critical thinking skills such as making interdisciplinary connections, predicting, generalizing, explaining, and making therapeutic judgments.
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Who is the primary decision maker in the care of healthy clients? Understand that family can give input but it is the patient who makes the decisions if they are capable and competent.
As in all phases of the nursing process, think of the client as a collaborative partner. Encourage the client and family to participate as much as possible in the client's care. Be aware that clients vary in their ability and desire to participate. Typically, the client implements health-promotion interventions, with little or no involvement by the nurse. To obtain the most benefit from an intervention, a client must be physically and psychologically ready. Clients are collaborative partners, not passive recipients of your care. Many interventions require their participation or cooperation. The following are caring reasons for taking time to explain. ■ Explaining the reasons for the action helps to motivate the person to participate. ■ Explaining what the person is expected to do gives the person the information she needs to participate. ■ Explaining what sensations the person can expect helps to relieve anxiety, enables the person to cope with unpleasant or painful sensations, and promotes a trusting relationship. People fail to follow therapeutic regimens for various reasons. They may not understand the routine or the reasons for it; there may be cultural objections to the therapy; their lifestyle may make adherence difficult (e.g., no time to exercise); they may be afraid of failing; they may be reluctant to ask questions, either from embarrassment at their lack of knowledge or from hesitance to "bother" a busy nurse or physician. You can promote cooperation with treatments and therapies by following these guidelines: 1. Assess the client's knowledge. Assess the client's understanding of his illness and the treatments and provide the necessary information. 2. Assess the client's supports and resources. 3. Be sensitive to the client's cultural, spiritual, and other needs and viewpoints. 3. Realize and accept that some attitudes cannot be changed. 4. Determine the client's main concerns. 5. Help the client to set realistic goals. 6. Talk openly and regularly about adherence.
Evidence-based practice (EBP)
Evidence-based practice (EBP) is an approach that uses firm scientific data rather than anecdote, tradition, intuition, or folklore in making decisions about medical and nursing practice. In nursing it includes blending clinical judgment and expertise with the best available research evidence and patient characteristics and preferences. The goal of evidence-based practice is to identify the most effective and cost-efficient treatments for a particular disease, condition, or problem. Steps in the EBP process include the following: ■ Formulating an answerable question about prevention, diagnosis, prognosis (likely outcome), and interventions ■ Conducting a systematic review of published evidence (research) to fi nd studies that shed light on the desired topic ■ Evaluating or grading the quality of the evidence obtained. Quality involves validity (closeness to the truth), applicability (usefulness), and impact (extent of the effect). ■ Compiling and analyzing the data to prepare a structured report of the review ■ "Translating" the evidence into guidelines for practice ■ Integrating the guidelines and evidence with clinical expertise and the patient's preferences and characteristics
What is differentiates an independent nursing intervention from other types of interventions (health promotion, treatment, and assessment interventions).
Nurses work collaboratively with other healthcare providers. Some things you do for patients will require a physician's order; many will not. Sometimes the activities of care providers overlap. An *independent intervention* is one that registered nurses are licensed to prescribe, perform, or delegate based on their knowledge and skills. It does not require a provider's order. Knowing how, when, and why to perform an activity makes the action autonomous (independent). As a rule, nurses prescribe and perform independent interventions in response to a nursing diagnosis. Understand you are accountable (answerable) for your decisions and actions with regard to nursing diagnoses and independent interventions. A *dependent intervention* is one that is prescribed by a physician or advanced practice nurse but carried out by the bedside nurse. Dependent interventions are usually orders for diagnostic tests, medications, treatments, IV therapy, diet, and activity. In addition to carrying out medical orders, you will be responsible for assessing the need for the order, explaining the activities to the patient, and evaluating the effectiveness of the order. An *interdependent (collaborative) intervention* is one that is carried out in collaboration with other health team members (e.g., physical therapists, dietitians, and physicians). Because nurses care for the whole person, their responsibilities often overlap with those of other team members.
➤ Nursing interventions are performed for the purpose of assessing health status, preventing and treating disease/illness, and promoting health.
➤ The RN is responsible for choosing interventions and writing nursing orders; however, the RN can delegate actual performance of some interventions to nursing assistive personnel (NAP) and LPN/LVNs.
