Clinical guideline

Or protocol is a document that guides decisions and interventions for specific health care problems or conditions

Standing orders

Is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for clients with identified clinical problems

Nursing Interventions Classification (NIC) interventions

Offer a level of standardization to enhance communication of nursing care across settings and to compare outcomes

What are the five preparatory activites for implementation of safe and effective nursing care.

1. Reassessing the client
2. Reviewing & Revising the existing nurse care plan
3. Organizing resources and care delivery
4. Anticipating and preventing complications
5. Implementation skills

Describe the preparatory implementation activity "Reassessing the client"

Continuous process that occurs each time you interact with a client; you collect new data, identify a new client need, and modify the care plan

Describe the preparatory implementation activity " Reviewing & Revising the existing nurse care plan"

If the client's status has changed and the nursing diagnosis and related nursing interventions are no longer appropriate, modify the nursing care plan

Describe the preparatory implementation activity "Organizing resources and care delivery"

Organization of equipment, skilled personnel, and the environment

Describe the preparatory implementation activity "Anticipating and preventing complications"

Risks to patients come from both the illness and the treatments

Describe the preparatory implementation activity "Implementation skills"

Includes cognitive (application of critical thinking in the nursing process), interpersonal (trusting relationship, level of caring and communication) and psychomotor skills (integration of cognitive and motor activities)

Define activities of daily living (ADLs)

Activities usually performed in the course of a normal day (ambulation, eating, dressing, bathing, grooming)

Instrumental activities of daily living include

Skills such as shopping, preparing meals, writing checks, taking medications

Physical care techniques include

Involve the safe and competent administration of nursing procedures

Counseling is

Is a direct care method that helps the client use a problem-solving process to recognize and manage stress and to facilitate interpersonal relationships

The focus of teaching is

is the intellectual growth or the acquisition of new knowledge or psychomotor skills

An adverse reaction is

Is a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention

Preventive nursing actions are

Promote health and prevent illness to avoid the need for acute or rehabilitative health care

Define interdisciplinary care plan

Represents the contributions of all disciplines caring for the client

Briefly describe the responsibility of the nurse for delegating and supervising others

Noninvasive and frequently repetitive interventions can be assigned to assistive personnel (nurse assistant). The nurse is responsible for ensuring that each task is appropriately assigned and is completed according to the standard of care.

Client adherence is

Is that clients and families invest time in carrying out required treatments to achieve client goals

(T or F) With standing orders, the nurse relies on the health care provider's judgment to determine if the intervention is appropriate?

True

The nursing care plan calls for the client, a 300-pound woman, to be turned every 2 hours. The client is unable to assist with turning. The nurse knows. that she may hurt her back if she attempts to turn the client by herself. The nurse should

Ask another nurse to help her turn the client

Mrs. Kay comes to the family clinic for birth control. The nurse obtains a health history and performs a pelvic examination and Pap smear. The Nurse is functioning according to

Protocol

Mary Jones is a newly diagnosed diabetic client. The nurse shows Mary how to administer an injection. This intervention activity is:

Teaching

instrumental activities of daily living (IADLs)

Activities that are required for an individual to be independent in society beyond eating, grooming, transferring, and toileting; these activities include writing a check, buying groceries, and preparing food.

Implementation

The fourth step of the nursing process, the nurse initiates the interventions that are most likely to achieve the goals and expected outcomes needed to support or improve the client's health status.

Implementation is the step of the nursing process in which nurses provides

Direct and indirect nursing care interventions to clients.

Always think first, and determine if an intervention is correct and appropriate before you

Implement

During the initial phase of implementation you should

reassess the client to determine whether the proposed nursing action is still appropriate for the client's level of wellness

The implementation of nursing care often requires

Additional knowledge, nursing skills, and personnel resources.

Before beginning to perform interventions, be sure the client is

As physically and psychologically comfortable as possible.

To anticipate and prevent complications, a nurse identifies

identifies risks to the client, adapts interventions to the situation, evaluates the relative benefit of a treatment versus the risk, and initiates risk prevention measures.

• • Successful implementation of nursing interventions requires you to use appropriate

cognitive, interpersonal, and psychomotor skills

The methods used to ensure that you administer physical care techniques appropriately include

protecting the nurse and client from injury, using proper infection control practices, staying organized, and following applicable practice guidelines

Counseling is a direct care method that helps clients use

problem solving to recognize and manage stress and to facilitate interpersonal relationships.

Preventive nursing actions include

assessment and promotion of the client's health potential, application of prescribed measures (e.g., immunizations), health teaching, and identification of risk factors for illness and/or trauma

To complete any nursing procedure, you need to

know the procedure, its frequency, the steps, and the expected outcomes.

Implementation

The fourth step of the nursing process,(formally begins after the nurse develops a plan of care) the nurse initiates the interventions that are most likely to achieve the goals and expected outcomes needed to support or improve the client's health status.

Nursing intervention

Is any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance client outcomes.Ideally the interventions a nurse uses are evidenced based, providing the most current, up-to-date, and effective approaches for managing patient problems. Interventions include direct and indirect care aimed at individuals, families, and/or the community.

Direct care (interventions)

Are treatments performed through interactions with patient's. Ex: Medication administration, insertion of an intravenous (IV) infusion, or counseling during a time of grief.

Indirect care (interventions)

Are treatments performed away from the patient but on behalf of the patient or group of patient's. Ex: Actions for managing patient's environment (e.g. safety and infection control), documentation, and interdisciplinary collaboration.

Critical Thinking in Implementation

Critical thinking is necessary to consider the complexity of interventions, including the number of alternatives approaches and the amount of time available to act. Before implementing a planned intervention, use critical thinking to confirm whether the intervention is correct and still appropriate for the patient's clinical situation.

Identify the factors that should be considered when making decisions about implementation

a. Review the set of all possible interventions for the patient's problem
b. Review all of the possible consequences associated with each possible nursing action
c. Determine the probability of all possible consequences
d. Make a judgment of the value of that consequence to the patient

Standard nursing interventions

Many patients have common health care problems; thus standardized interventions for these health problems make it quicker and easier for nurses to intervene. ->Nurse/Physician initiated standardized interventions- Clinical guidelines or protocols, Preprinted (standing) orders, and Nursing Interventions Classification (NIC) interventions. ->Professional level- The American Nurses Association (ANA) defines standards of professional nursing practice, which include standards for the implementation step of the nursing process.

Clinical practice guideline

Or protocol is a document that guides decisions and interventions for specific health care problems or conditions. (or protocol) Is a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations.

Standing orders

Is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for patients with identified clinical problems.

Nursing Interventions Classification (NIC) interventions

Offer a level of standardization to enhance communication of nursing care across settings and to compare outcomes

What are the five preparatory activites for implementation of safe and effective nursing care.

1. Reassessing the patient
2. Reviewing & Revising the existing nurse care plan
3. Organizing resources and care delivery
4. Anticipating and preventing complications
5. Implementation nursing interventions

1. "Reassessing the patient"

Reassessing the patient is a continuous process that occurs each time you interact with a patient; you collect new data, identify a new patient need, and modify the care plan

2. " Reviewing & Revising the existing nurse care plan"

If the patient's status has changed and the nursing diagnosis and related nursing interventions are no longer appropriate, modify the nursing care plan

3. "Organizing resources and care delivery"

Organizing resources and care delivery involves organization of equipment, skilled personnel, and the environment. This makes timely, efficient, skilled patient care possible.

4. "Anticipating and preventing complications"

Risks to patients come from both the illness and the treatments

5. "Implementation skills"

Implementation skills includes cognitive (application of critical thinking in the nursing process), interpersonal (trusting relationship, level of caring and communication) and psychomotor skills (integration of cognitive and motor activities).

Activities of daily living (ADLs)

Activities usually performed in the course of a normal day (ambulation, eating, dressing, bathing, grooming)

Instrumental activities of daily living include (IADL's)

Skills such as shopping, preparing meals, writing checks, taking medications

Physical care techniques include

Involve the safe and competent administration of nursing procedures. Common methods for administering physical care techniques appropriately include protecting you and the patient from injury, using safe patient handling techniques, using proper infection control practices, staying organized, and following applicable practice guidelines.

Counseling

Is a direct care method that helps a patient use a problem-solving process to recognize and manage stress and to facilitate interpersonal relationships

The focus of teaching is

is the intellectual growth or the acquisition of new knowledge or psychomotor skills

Adverse reaction

Is a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention

Preventive nursing actions

Promote health and prevent illness to avoid the need for acute or rehabilitative health care. -Primary prevention aimed at health promotion and illness prevention. -Secondary prevention focuses on people who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. -Tertiary prevention involves minimizing the effects of long-term illness or disability, including rehabilitation measures.

Interdisciplinary care plan

Represents the contributions of all disciplines caring for the client. The record entry usually includes a brief description of pertinent assessment findings, the specific intervention, and the patient's response.

Briefly describe the responsibility of the nurse for delegating and supervising others

Noninvasive and frequently repetitive interventions can be assigned to nursing assistive personnel (NAP). The nurse is responsible for ensuring that each task is appropriately assigned and is completed according to the standard of care. (Indirect care activity) When performed correctly, delegation ensures that the right care provider performs the right tasks so the nurse and the NAP work most efficiently together for the patient's benefit.

Patient adherence

Patients and families invest time in carrying out required treatments to achieve patient goals

(T or F) With standing orders, the nurse relies on the health care provider's judgment to determine if the intervention is appropriate?

True

The nursing care plan calls for the patient, a 300-pound woman, to be turned every 2 hours. The client is unable to assist with turning. The nurse knows. that she may hurt her back if she attempts to turn the client by herself. The nurse should

Ask another nurse to help her turn the client

Mrs. Kay comes to the family clinic for birth control. The nurse obtains a health history and performs a pelvic examination and Pap smear. The Nurse is functioning according to

Protocol

Mary Jones is a newly diagnosed diabetic client. The nurse shows Mary how to administer an injection. This intervention activity is:

Teaching

Implementation is the step of the nursing process in which nurses provides

Direct and indirect nursing care interventions to clients.

During the initial phase of implementation you should

Reassess the client to determine whether the proposed nursing action is still appropriate for the client's level of wellness.

The implementation of nursing care often requires

Additional knowledge, nursing skills, and personnel resources.

Before beginning to perform interventions, be sure the client is

As physically and psychologically comfortable as possible.

To anticipate and prevent complications, a nurse

identifies risks to the client, adapts interventions to the situation, evaluates the relative benefit of a treatment versus the risk, and initiates risk prevention measures.

• • Successful implementation of nursing interventions requires you to use appropriate

cognitive, interpersonal, and psychomotor skills

The methods used to ensure that you administer physical care techniques appropriately include

protecting the nurse and client from injury, using proper infection control practices, staying organized, and following applicable practice guidelines

Counseling is a direct care method that helps clients use

problem solving to recognize and manage stress and to facilitate interpersonal relationships.

To complete any nursing procedure, you need to

know the procedure, its frequency, the steps, and the expected outcomes.