Lippincott for Taylor: Fundamentals of Nursing Chapter 17- Implementing

A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which step should the nurse consider a priority on the nursing care plan?

**monitor for lactic acidosis

What is a rationale?

- Supports why nursing action is necessary - Needed for each nursing intervention - Sources must be credible

What are the advantages of using standard Nursing Interventions Classifications (NIC)?

-Teaching decision making -Allocating nursing resources -Developing information systems -Communicating nursing to non-nurses

When implementing a care plan, every nurse should:

1) Be sure that each nursing intervention is supported by a sound scientific rationale, as demanded by evidence-based practice 2) Be sure that each nursing intervention is consistent with professional standards of care and consistent with the protocols, policies, and procedures of the institution or facility 3) Be sure that the nursing actions are safe for this particular patient and individualized to his or her preferences 4) Clarify any questionable orders

When carrying out 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 3) Assist the patient to achieve valued health outcomes

Successful nurses modify their nursing actions according to what variables?

1) changing ability and willingness to participate in the care plan 2) previous responses to nursing interventions and progress toward achieving goals or outcomes.

What are the 3 aims of the Nursing Outcomes Classification (NOC)?

1) identify, label, validate, and classify nursing-sensitive patient outcomes and indicators 2) Evaluate the validity and usefulness of the classification in clinical field testing 3) Define and test measurement procedures for the outcomes and indicators

During the implementation step of the nursing process, a nurse reviews and revises the nursing plan of care. Place the following steps of review and revision in correct order: 1. Review the care plan 2. Decide if the nursing interventions remain appropriate 3. Reassess the patient 4. Compare assessment findings to validate existing nursing diagnoses

3, 1, 4, 2

Which type of nursing intervention is oxygen administration and why is it considered to be so?

A dependent nursing intervention, because oxygen is considered a drug that requires a physician's order

The nurse is caring for a client admitted to the hospital for renal calculi. What is the action to take first?

Assess for bladder distention. Urinary retention could occur if a kidney stone has become lodged in the urethra

The nurse has assessed the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention?

Assess the client's response to the ambulation

Why is it important for you as the nurse to make rounds with other health care professionals & to read the results of consultations that patients have had with specialists?

Care can easily become fragmented when patients are seen by numerous specialists—each interested in a different aspect of the patient—and in different settings

Which parties are essential for the nurse to include in the implementation of a client's plan of care?

Client, family, and physician

A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action?

Collaborate with other disciplines to plan end-of-life care for the client. To respect the client's wishes, the nurse should involve other disciplines, such as hospice care, in planning for the client's needs

Nurse-Health Care Team Relationships

Communicate clearly nursing's perspective regarding the patient and family to the health care team. Coordinate the inputs of the multidisciplinary team into a comprehensive care plan. Serve as a liaison between the patient and family and the health care team, as necessary.

Nurse-Patient Relationship

Communicate to patients that someone is concerned about them (as well as the disease) and is interested in how change in health state will affect their overall well-being. Create an environment in which patients can commit their energies to health promotion or restoration or peaceful dying, confident that basic human needs are being addressed. Challenge patients to develop self-care abilities that promote holistic health.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Communicate with the health care provider for additional orders. If the nurse's interventions have been ineffective, the health care provider must be notified of the client's deteriorating status

Nurses can fail patients by doing too much for them and by encouraging negative, sick-role behaviors, such as inappropriate _________________.

Dependence

Nurse-Patient-Family relationship

Develop in the patient and family the knowledge, attitude, and skills that will enable them to respond to the self-care challenges of their health or illness state. Intervene as appropriate to promote healthy family functioning. Educate the family to be wise and assertive health care consumers.

The nurse in a burn intensive care unit is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?

Ensuring that the endotracheal tube is secure

What are error correction strategies?

Error correction strategies: persevering, being physically present, reviewing or confirming the care plan, offering options, referencing standards or experts, and involving another nurse or health care provider

What are error identification strategies?

Error identification strategies: knowing the patient, knowing the "players," knowing the care plan, surveillance, knowing policy and procedure, double-checking, using systematic processes, and questioning

What are error interruption strategies?

Error interruption strategies: offering help, clarifying, and verbally interrupting

What are common reasons for patient noncompliance?

Lack of family support Lack of understanding about the benefits of compliance Low value attached to outcomes or related interventions Adverse physical or emotional effects of treatment (such as pain and fatigue) Inability to afford treatment Limited access to treatment

For collaborative problems, interventions seek to:

Monitor for changes in status Manage changes in status with nurse-prescribed and health care provider-prescribed interventions Evaluate response

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?

Nurse case manager- the nurse case manager is the expert on resources available for the client's care

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?

Outcome Explanation: Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care, such as an expedited discharge of the client based on the client recovering more quickly due to an intervention. The focus of a process evaluation is the nature and sequence of activities carried out by nurses implementing the nursing process. A structure evaluation or audit focuses on the environment in which care is provided. Cost-effectiveness is not a type of evaluation identified by the American Nurses Association.

The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment?

Perform vital signs and blood glucose level. The results of the assessment could help determine which actions to take next

Which action is a responsibility of the nurse in the nurse-nurse team relationship?

Provide creative leadership to make the nursing unit a challenging place to work.

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

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include?

Risk factors for and prevention of diabetes mellitus

When choosing nursing interventions, the nurse should consider and respect the patient's _____________________ background and culture.

Socioeconomic

What's the difference between protocols & standing orders?

Standing orders typically require the supervision of a health care provider; Whereas protocols do not

Nurse-Nurse Relationship

Support one another's efforts to deliver quality nursing care; work collaboratively with nursing administration to improve quality care. Provide creative leadership—formally or informally—to make the nursing unit a satisfying and challenging place to work. Supervise the nursing care given by other nursing personnel; affirm the nursing strengths of others, and constructively address the nursing deficiencies encountered. Enhance the professional development of self and other nurses through active participation in professional organizations.

While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention?

Surveillance

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?

The client with continuous pulse oximetry who requires pharyngeal suctioning. The client requires the nurse to evaluate the client's response in pulse oximetry to the suctioning

The client is having difficulty breathing. The respiratory rate is 44 & the oxygen saturation is 89%. The nurse raises the head of the bed and applies oxygen at 3L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions?

The client's respiratory rate decreases The client states, "I can breathe easier now" The client's oxygen saturation level increases

The joint commission (TJC) encourages clients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving client safety by encouraging them to speak up?

The nurse encourages the client to participate in all treatment decisions as the center of the health care team.

A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action?

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.

What is the purpose of implementing step of the nursing process?

To help the patient achieve valued health outcomes, including: -promote health, -prevent disease and illness, -restore health, and -facilitate coping with altered functioning.

As a student, when is it your responsibility to ask for help?

When you doubt that your cognitive, interpersonal, or technical competencies are adequate to successfully implement the care plan

What is a nursing intervention?

any treatment based on clinical judgment and nursing knowledge that a nurse performs to enhance patient outcomes

What is Alfaro's Rule?

assess, reassess, revise, record Assess patients before performing nursing actions. Re-assess them to determine their responses after you perform nursing actions. Revise your approach as indicated. Record patient responses and any changes you made in the care plan.

For possible nursing diagnoses, interventions seek to:

collect additional data to rule out or confirm the diagnosis

The nurse's ______________________ to a large degree determines how successfully the plan is implemented

competence

What are standing orders?

document that details the nursing care to be implemented in specific nursing situations, frequently when a physician is not present; may expand scope of nursing responsibilities

Community interventions ______________ the health promotion, health maintenance, and disease prevention of populations and include strategies to address the social and political climate in which the population resides.

emphasize

What factors may interfere with someone's usual practice of self-care?

illness and the stress of diagnostic and therapeutic measures

Nurse variables that influence the implementation of the care plan include:

levels of expertise, creativity (ability to match patient needs with specific nursing strategies), willingness to provide care, and available time.

What is clinical inquiry?

ongoing process of questioning and evaluating practice, providing informed practice, and innovating through research and experiential learning

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention?

surveillance

What is the nurse's concern in all nurse-patient interactions?

the nurse is concerned with the patient's response to health and illness and the patient's ability to meet basic human needs.

What is an indirect care intervention?

treatment performed away from the patient but on behalf of a patient or group of patients

What is a direct care intervention?

treatment performed through interaction with the patient

What are protocols?

written plans that detail the nursing activities to be executed in specific situations