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IMPLEMENTATION AND EVALUATION, CHAPTER 6, FUNDAMENTALS OF NURSING

FUNDAMENTALS OF NURSING BY PAMELA SUE

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4TH STEP IN THE NURSING PROCESSIMPLEMENTATION
IMPLEMENTATIONFOLLOWS ASSESSMENT, NURSING DIAGNOSIS AND PLANNING
5TH STEP IN THE ANA STANDARD V:IMPLEMENTATION
IMPLEMENTATIONCARRYING OUT PHASE, THE NURSING INTERVENTIONS (ACTIONS) ARE CARRIED OUT LISTED ON THE NURSING CARE PLAN
IMPLEMENTING CARE FOR A GROUP OF PATIENTS REQUIRESGOOD WORK ORGANIZATION
FIRST IN ORDER ISPRIORITIES
CHANGE OF SHIFT REPORTGIVES CLUES ABOUT HIGH PRIORITY TASKS AND IMMINENT DEADLINES FOR CERTAIN TASKS TO BE ACCOMPLISHED
IMPORTANT INFO FROM THE CHANGE OF SHIFT REPORT1. TIME RELATED TASKS FOR EACH ASSIGNED PATIENT (EX. IV FLOW RATE AND THE FLUID THAT WILL BE USED WHEN THE IV BAG IS CHANGED, TIME, DOSE) NEXT COULD BE THE LAST TIME THE PATIENT REC'D HIS MEDS, IF THE PATIENT SHOULD HAVE MEDS FOR PREOP AT 8AM, THE PREOP ROUTINE SHOULD BE COMPLETED PRIOR TO THAT TIME, NEXT PERSONAL NEEDS, TISSUES, ICE, ETC
TIME FLEXIBLECAN BE DONE ANYTIME, TASKS ARE ENTERED ONTO THE WORKSHEET SCHEDULE BETWEEN TIMEFIXED TASKS
TIME FIXED TASKSMUST BE DONE AT A SET TIME
CRITICAL THINKINGIS ESSENTIAL TO FORM A GOOD WORK PLAN
WHEN PLANNING TIME FOR UNINTERRUPTED CARE CONSIDER:IF VISITORS ARE COMING, WHEN DIAGNOSTIC TESTS ARE SCHEDULED, WHAT TIME DR IS COMING TO SEE PATIENT, MED SCHEDULES
WORK SCHEDULESMAY NEED TO BE REVISED AFTER THE INITIAL SHIFT ASSESSMENT
PRIORITIES OF CARE FOR THE PATIENTMAY NEED TO BE ALTERED IF THE PATIENTS CONDITION HAS BECOME MORE ACUTE
IMPLEMENTATION (CONSIDERATIONS FOR CARE DELIVERY)BEFORE CARRYING OUT THE SPECIFIC INTERVENTIONS LISTED ON THE PLAN OF CARE, IDENTIFY THE REASON FOR THE INTERVENTION, THE USUAL STANDARD OF CARE, THE EXPECTED OUTCOME, AND ANY POTENTIAL DANGERS
A DANGERMIGHT BE THE POSSIBILITY OF INTRODUCING MICROORGANISMS DURING AN INVASIVE PROCEDURE
EACH INTERVENTION IS EITHERINDEPENDENT NURSING ACTION OR DEPENDENT NURSING ACTION
INDEPENDENT NURSING ACTIONDOES NOT REQUIRE A DRS ORDER, BUT IT DOES REQUIRE CRITICAL THINKING
INDERPENDENT NURSING ACTIONTEACHING A PATIENT ABOUT THE SIDE EFFECTS OF A MED
DEPENDENT NURSING ACTIONREQUIRES A DRS ORDER
DEPENDENT NURSING ACTIONADMINISTRATION OF A MED BECAUSE IT REQUIRES A RX
BACK MASSAGEINDERPENDENT NURSING ACTION
ORDERING A HEATING PAD AND APPLYING IT TO A PATIENTDEPENDENT NURSING ACTION
ASSISTING A SPEECH THERAPISTINDERPENDENT NURSING ACTION
INDERPENDENT ACTIONSCOME FROM COLLABORATIVE CARE PLANNING
COLLABORATIVE TYPE OF PLAN OF CARE REFERRED TO AS ACRITICAL PATHWAY, A CARE PATH, INTERDISCIPLINARY CARE MAP, STEP BY STEP APPROACH TO THE TOTAL CARE OF THE PATIENT
CRITICAL PATHWAY, MULTIDISCIPLINARY APPROACH TO PATIENT CAREIS AN OUTGROWTH OF MANAGED CARE
THE NURSING CARE PLAN IS NOT PART OF THE PATIENTS CHART WHEN A CRITICAL PATHWAY IS USEDHOWEVER, THE NURSING PROCESS IS UTILIZED
EVALUATION ISJUDGEMENT OF THE EFFECTIVENESS OF THE INTERVENTION OR PLAN, PATHWAYS ARE STANDARD FOR PARTICULAR MEDICAL DIAGNOSIS, THEN CUSTOMIZED FOR THE PATIENT AT THE TIME OF ADMISSION. A CASE MANAGER IS IN CHARGE OF REVIEWING PATIENTS PROGRESS, ALONG THE PATH TO SEE THAT ACTIONS ARE CARRIED OUT AND TO SEE IF THE PATIENT WILL ACHIEVE THE EXPECTED OUTCOMES IN THE TIME LINE. COST EFFECTIVE IN THE DELIVERY OF HEALTH CARE.
IMPLEMENTATION (IMPLEMENTING CARE)WHEN A NURSING INTERVENTION ON THE CARE PLAN CALLS FOR A PROCEDURE TO BE PERFORMED, REVIEW THE HOSPITAL PROCEDURE MANUAL REGARDING THE PARTICULAR STEPS INVOLVED
EACH HOSPITAL OR WORKPLACEHAS PARTICULAR REQUIREMENTS FOR THE WAY A PROCEDURE IS TO BE CARRIED OUT
EMPLOYEES AND STUDENTSARE EXPECTED TO PERFORM AT THE DESIGNATED STANDARD OF CARE LISTED IN THE PROCEDURE MANUAL
STUDENT NURSE IN CLINICALSCARE ON RN'S TEACHERS LICENSE, SHOULD BE ABLE TO PERFORM ON LPN LEVEL
FOR EFFICIENT USE OF TIMECONSIDER WHICH INTERVENTIONS CAN BE COMBINED,
BATHS AND BED MAKINGCOMBINED
TIME IN THE ROOM GATHER MORE INFO, TEACHING PLANCOMBINED
RANGE OF MOTION EXERCISES, BATH ROUTINECOMBINED
THERE ARE SOME STANDARD STEPS THAT ARE ALWAYS FOLLOWEDWHEN PERFORMING A NURSING PROCEDURE, STEPS ARE BASED ON THE ANA STANDARDS OF CLINICAL PRACTICE, RIGHTS OF PATIENTS, SAFE NURSING PRACTICE
CLINICAL PATHWAY INCLUDESICD-9 CODE, ELOS, NURSING DIAGNOSIS, COLLABORATIVE PROBLEM, EXPECTED OUTCOME (PATIENT IS EXPECTED TO), MET/NOT MET, REASON, DATE/INITIALS, ASPECT OF CARE, ASSESSMENT, TEACHING, CONSULTS, LAB TESTS, OTHER TESTS, MEDS, TREATMENTS/INTERVENTIONS, NUTRITION, LINES,TUBES,MONITORS, MOBILITY/SELF CARE, DISCHARGE PLANNING
IMPLEMENTATION (DOCUMENTATION OF THE NURSING PROCESS)EACH TIME A PROCEDURE IS PERFORMED, MED GIVEN, VITAL SIGNS, SOMETHING IS DONE, A NOTATION MUST BE MADE IN THE CHART
NURSES NOTESMUST INDICATE THAT THE NURSING CARE HAS BEEN CARRIED OUT
IF AN INTERVENTION ON THE CARE PLAN IS NOT MENTIONED IN CHARTINGIT IS CONSIDERED NOT DONE
IT IS WISE TO REVIEW THE NURSING CARE PLAN BEFORE BEGINNING CARETO HAVE A CLEAR IDEA OF ALL OF THE AREA THAT NEED WRITTEN DOCUMENTATION
DOCUMENTATIONRECORDING OF PERTINENT DATA ON THE CLINICAL RECORD
MOST HOSPITALS REQUIRE ANOTATION ABOUT EACH PROBLEM OR NURSING DIAGNOSIS AT LEAST ONCE Q24H
AFTER IMPLEMENTING CARE FOR THE PATIENTDOCUMENT THAT CARE ON THE PATIENTS CHART
ITEMS RECORDEDBATHING ON THE ACTIVITY FLOW SHEET
NEW PROBLEM ARISESA NURSES NOTE IS REQUIRED TO DOCUMENT THE ASSESSMENT FINDINGS, NURSING DIAGNOSIS, AND THE PLAN TO CORRECT OR ALLEVIATE THE PROBLEM
THE SOONER CARE IS DOCUMENTEDTHE BETTER
MOST HOSPITALS REQUIRE NURSESDOCUMENT (CHART) ON EACH PATIENT Q2H
STANDARD STEPS FOR ALL NURSING PROCEDURESAT THE BEGINNING OF THE PROCEDURE
STEP A: CHECK YOUR ORDER, COLLECT THE EQUIPMENT AND SUPPLIES, AND WASH YOUR HANDSVERIFY THE PROCEDURE, CHECK AGENCIES POLICIES & PROCEDURES, PROCESS EQUIPMENT AND SUPPLY CHARGES, TAKE ALL EQUIPMENT AND SUPPLIES TO THE PATIENTS ROOM
STEP B: IDENTIFY AND PREPARE THE PATIENTGREET, INTRODUCE YOURSELF, CHECK PATIENTS ID BAND, EXPLAIN WHAT YOU ARE GOING TO DO IN TERMS THE PATIENT CAN UNDERSTAND, ELICIT QUESTIONS AND ANSWER CLEARLY, PROVIDE TEACHING RELATED TO THE PROCEDURE TO BE PERFORMED
STEP C: PROVIDE PRIVACY AND INSTITUTE SAFETY PRECAUTIONS, ARRANGE THE SUPPLIES AND EQUIPMENTCLOSE DOOR, CURTAINS/DRAPE BEFORE BEGINNING PROCEDURE OR DISCUSSING INFO THE PATIENT MIGHT WANT TO KEEP PRIVATE., SET UP THE EQUIPMENT AND SUPPLIES IN AN ORDERLY, METHODICAL FASHION, RAISE THE BED TO THE RIGHT WORKING HEIGHT, RAISE THE SIDERAIL BEFORE TURNING THE PATIENT AND BE CERTAIN THE WHEELS ARE LOCKED, WASH HANDS AGAIN, TO PREVENT CONTAMINATION THE PATIENT WITH ORGANISMS FROM THE CHART, NURSES STATION AND THE SUPPLY ROOM
DURING THE PROCEDURE, STEP D: USE STANDARD PRECAUTIONS AND ASEPTIC TECHNIQUE AS APPROPRIATEPROTECT YOURSELF FROM BLOOD & BODY FLUIDS BY WEARING GLOVES, GLASSES, GOGGLES AND IMPERMEABLE COVER GOWN OR APRON.BE VERY CAREFUL WITH SHARP INSTRUMENTS AND NEEDLES SO AS NOT TO NICK YOUR SKIN
STEP E: PERFORM THE TASK ACCORDING TO PROTOCOLMENTALLY REVIEW THE STEPS OF THE TASK BEFOREHAND, IF YOU ARE UNCERTAIN, ASK A TEAM LEADER, RESOURCE NURSE, INSTRUCTOR, OR CHARGE NURSE. PLAN FOR EFFICIENCY OF TIME AND EFFORT WHILE DELIVERING SAFE CARE
AT THE END OF THE PROCEDURE STEP X: REMOVE GLOVES AND OTHER PROTECTIVE EQUIPMENTMAKE SURE PATIENT IS CLEAN AND DRY, DISPOSE OF USED SUPPLIES, REMOVE GOGGLES,APRON, GLOVES, DISCARD APPROPRIATELY, TO REMOVE GLOVES WITHOUT CONTAMINATING YOURSELF, BEGIN BY PULLING ONE GLOVE OFF WITHOUT TOUCHING YOUR SKIN, HOLD THE REMOVED GLOVE IN THE PALM OF THE REMAINING GLOVED HAND AND THEN REACH TO THE INSIDE OF THE OTHER GLOVE AND ROLL IT DOWN THE HAND, DISPOSE OF THE GLOVES IN THE TRASH, WASH HANDS IMMEDIATELY
STEP Y: RESTORE THE UNIT, COLLECT THE USED EEQUIPMENT AND DISPOSE, CLEAN OR STORE ITEMS IN THE PROPER PLACESMAKE THE PATIENT COMFORTABLE, TIDY THE BED AND UNIT, CALL LIGHT AND PERSONAL ITEMS WITHIN REACH, PROVIDE SAFETY (BEDRAILS RAISED OR LOWERED), REMOVE USED EQUIPMENT, SOILED LAUNDRY IN HAMPER, REUSABLE ITEMS ARE CLEANED AND RETURNED TO THE STORAGE/CENTRAL SUPPLY. DISCONTINUE USE OF THE EQUIPMENT ON THE COMPUTER SO NO FURTHER CHARGES WILL BE MADE, REMOVE UNSIGHTLY, ODOROUS TRASH FROM THE ROOM, INQUIRE IF THEY NEED ANYTHING ELSE, WASH HANDS AGAIN
STEP Z: RECORD AND REPORT THE PROCEDUREDOCUMENT ASSESSMENT FINDINGS, AND DETAILS OF PROCEDURE PERFORMED IN THE CHART. INCLUDE ANY PROBLEMS, REPORT SHOULD BE ACCURATE, SPECIFIC, CONCISE AND APPROPRIATE, AND THE TIME, INITIALS, REPORT ANY ABNORMALITIES TO THE CHARGE NURSE OR DR.
5TH AND FINAL STEP TO THE NURSING PROCESSEVALUATION
ANA STANDARD VIEVALUATION
EVALUATIONONCE THE INTERVENTIONS ARE CARRIED OUT, YOU MUCH DETERMINE WHETHER THEY WERE EFFECTIVE IN THE PATIENTS EXPECTED OUTCOMES. IF THEY WERE REACHED, THEY WERE MET, COMPARE ACTUAL OUTCOMES TO THE EXPECTED OUTCOMES WHETHER PROGRESS WAS MADE.
EVALUATIONIS A CONTINUOUS PROCESS
EVALUATION (REVISION OF A NUSING CARE PLAN)INEFFECTIVE INTERVENTIONS MUST BE REVISED, IF THE INTERVENTIONS HAVE BEEN EFFECTIVE AND THE NURSING DIAGNOSIS IS NO LONGER APPLICABLE, IT IS MARKED "RESOLVED" ON THE NURSING CARE PLAN.
IF THE EXPECTED OUTCOMES ARE CONSIDERED METTHE NURSES NOTES MUST CONTAIN DATA TO SUPPORT THIS
NURSING CARE PLANS REVISEAS OFTEN AS Q24H WITH RESOLVED PROBLEMS INACTIVATED, NEW PROBLEMS ADDED, INTERVENTIONS REVISED, AND PROGRESS TOWARD OUTCOMES EVALUATED.THIS IS FREQUENTLY DONE ON THE UNIT COMPUTER.
EACH NURSE DETERMINES WHETHERTHERE IS A BETTER, MORE EFFICIENT INTERVENTION TO HELP THE PATIENT ACHIEVE THE EXPECTED OUTCOMES.
CONSTANT EVALUATIONIS AN INTEGRAL PART OF EVERY ASPECT OF NURSING
QUALITY MANAGEMENTEVALUATION OF NURSING PRACTICE INCLUDES DETERMINING WHETHER NURSING PRACTICE HAS BEEN PERFORMED IN A COST EFFECTIVE, TIME EFFICIENT MANNER
CONTINUOUS QUALITY IMPROVEMENT (CQI)IMPROVE THE QUALITY OF PERFORMANCE PROGRAMS ARE USED TO EVALUATE NURSING CARE DELIVERED TO PATIENTS. THE GOAL IS THE IMPROVEMENT OF NURSING PRACTICE
CGITHIS PROGRAM IS USUALLY AGENCY WIDE, WORKING WITH NURSING AUDITS, COMPLIANCE WITH STANDARDS IN EVERY DEPT
NURSING AUDITIS EXAMINATION OF A SERIES OF PATIENT RECORDS TO DETERMINE IF NURSING CARE FOR THOSE PATIENTS MET PARTICULAR STANDARDS
EVERY HOSPITAL MUST PERFORMMEDICAL AND NURSING AUDITS TO ACHIEVE AND MAINTAIN ACCREDITATION
PROCESS EVALUATIONLOOK AT THE ACTIVITIES OF THE NURSES AND WHAT THEY HAVE DONE TO ASSESS, PLAN, IMPLEMENT, AND EVALUATE NURSING CARE
PROCESS EVALUATION CRITERIAARE THE STANDARDS OF CLINICAL NURSING PRACTICE DEVELOPED BY THE ANA
PURPOSE OF EVALUATING NURSING CAREIS TO ACHIEVE CONTINUOUS QUALITY IMPROVEMENT BY IDENTIFYING SPECIFIC AREAS THAT NEED CHANGES.
EVALUATIONIS NOT PERFORMED TO BLAME SOMEONE FOR CARELESSNESS, INCOMPETENCE OR INEFFICIENCY
NURSES ON A UNITOFTEN ROTATE AS THE QUALITY MANAGEMENT PERSON FOR THE UNIT SO THAT EVERYONE IS INVOLVED IN THE PROCESS
CONSTRUCTING A NURSING CARE PLANRN MAY CONSTRUCT THE INITIAL NURSING CARE PLAN OR IN A LONG TERM FACILITY, THE LPN MAY CONSTRUCT A PRELIMINARY NURSING CARE PLAN THAT AN RN WILL REVIEW, CHANGE AS NEEDED
STUDENTSARE REQUIRED BY INSTRUCTORS TO COME TO CLINICALS WITH A NURSING CARE PLAN IN HAND FOR THEIR ASSIGNED PATIENTS
STEPS FOR CONSTRUCTING A NURSING CARE PLAN, PERFORM AN ASSESSMENT AND GATHER A DATABASE ON A PATIENTOBTAIN PT HISTORY, PERFORM PHYSICAL ASSESSMENT, REVIEW CHART, NOTING DATA AND LAB VALUES TO THE PATIENTS PROBLEM OR ADMITTING DIAGNOSIS)
STEP 2, CONSTRUCTING A NURSING CARE PLAN,ANALYZE THE DATABASE TO DETERMINE CURRENT AND POTENTIAL PROBLEMSGROUP DATA ACCORDING TO BODY SYSTEM, REVIEW AREAS OF ABNORMALITES OR PROBLEMS. IDENTIFY PROBLEMS, COLLABORATE WITH THE PT TO SEE THAT HE OR SHE ALSO CONSIDERS EACH ONE A PROBLEM)
STEP 3, CONSTRUCTION OF A NURSING CARE PLAN, (CHOOSE APPROPRIATE NURSING DIAGNOSES BASED ON DEFINING CHARACTERISTICS OF THE PATIENTS PROBLEMS)STATE THE NURSING DIAGNOSIS FROM NANDA TERM. PROBLEM+CAUSE+SIGNS
STEP 4 CONSTRUCTING A NURSING CARE PLAN (RANK THE NURSING DIAGNOSES IN ORDER OF PRIORITY)CONFER WITH THE PT ABOUT THE PRIORITIES OF THE PT'S PROBLEMS AND NEEDS. PHYSIOLOGIC NEEDS FOR AIR AND CIRCULATION ARE FIRST AND SECOND AND MUST BE MET FIRST, NUMBER THE DIAGNOSES ACCORDING TO PRIORITY
STEP 5 CONSTRUCTING A NURSING CARE PLAN (PLAN THE NURSING CARE BY DEFINING GOALS AND WRITING EXPECTED OUTCOMES)DEFINE OVERALL GOALS, WRITE SPECIFIC EXPECTED OUTCOMES, EASY TO DETERMINE THRU EVALUATION, TIME FRAME
STEP 6 CONSTRUCTING A NURSING CARE PLAN (PLAN NURSING CARE BY CHOOSING APPROPRIATE NURSING INTERVENTIONS THAT WILL ASSIST IN ACHIEVING THE OUTCOMES)CONSIDER ALL INTERVENTIONS PERTAINING TO PROBLEM, CHOOSE THOSE THAT ARE MORE HELPFUL FASTER, DO THIS FOR EACH DIAGNOSIS ON THE PATIENTS LIST
STEP 7, CONSTRUCTING A NURSING CARE PLAN (IMPLEMENT THE NURSING INTERVENTIONS)PLACE THE NURSING CARE PLAN IN THE CHART OR KARDEX OR COMPUTER. COMMUNICATE THE PLAN OF CARE TO STAFF MEMBERS ON OTHER SHIFTS, CARRY OUT THE NURSING INTERVENTIONS USING THE STANDARD STEPS FOR ALL NURSING PROCEDURES
STEP 8, CONSTRUCTING THE NURSING CARE PLANEVALUATE THE ACTUAL OUTCOMES VS EXPECTED OUTCOMES, REASSESS, MAKE REVISIONS, ADD NEW OR DELETE NURSING DIAGNOSES ACCORDING TO PT PROGRESS
INDERPENDENT ACTION (NOT INDERPENDENT NURSING ACTION)IS ONE DERIVED FROM COLLABORATIVE PLANNING BETWEEN TWO OR MORE HEALTH CARE PROFESSIONALS
ASSISTING WITH A BATH, CHANGES DRESSING, RUBS BACK, GIVE MEDS, WALKS HIM, WHICH ONE IS INDERPENDENT NURSING ACTION?BACK RUB
DEPENDENT NURSING ACTION IS?ONE FOR WHICH A DR'S ORDER IS WRITTEN
NURSE EVALUATES HIS CARE BY DETERMINING?WHETHER EXPECTED OUTCOMES HAVE BEEN ACHIEVED
IF EVALUATION DETERMINES THAT OUTCOMES ARE NOT BEING ACHIEVED?A NURSING CARE PLAN IS REVISED
NURSING AND MEDICAL AUDITS?ARE ESSENTIAL FOR HOSPITAL ACCREDITATION


Pamela Sue

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