| A | B |
|---|
| 4TH STEP IN THE NURSING PROCESS | IMPLEMENTATION |
| IMPLEMENTATION | FOLLOWS ASSESSMENT, NURSING DIAGNOSIS AND PLANNING |
| 5TH STEP IN THE ANA STANDARD V: | IMPLEMENTATION |
| IMPLEMENTATION | CARRYING OUT PHASE, THE NURSING INTERVENTIONS (ACTIONS) ARE CARRIED OUT LISTED ON THE NURSING CARE PLAN |
| IMPLEMENTING CARE FOR A GROUP OF PATIENTS REQUIRES | GOOD WORK ORGANIZATION |
| FIRST IN ORDER IS | PRIORITIES |
| CHANGE OF SHIFT REPORT | GIVES CLUES ABOUT HIGH PRIORITY TASKS AND IMMINENT DEADLINES FOR CERTAIN TASKS TO BE ACCOMPLISHED |
| IMPORTANT INFO FROM THE CHANGE OF SHIFT REPORT | 1. 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 FLEXIBLE | CAN BE DONE ANYTIME, TASKS ARE ENTERED ONTO THE WORKSHEET SCHEDULE BETWEEN TIMEFIXED TASKS |
| TIME FIXED TASKS | MUST BE DONE AT A SET TIME |
| CRITICAL THINKING | IS 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 SCHEDULES | MAY NEED TO BE REVISED AFTER THE INITIAL SHIFT ASSESSMENT |
| PRIORITIES OF CARE FOR THE PATIENT | MAY 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 DANGER | MIGHT BE THE POSSIBILITY OF INTRODUCING MICROORGANISMS DURING AN INVASIVE PROCEDURE |
| EACH INTERVENTION IS EITHER | INDEPENDENT NURSING ACTION OR DEPENDENT NURSING ACTION |
| INDEPENDENT NURSING ACTION | DOES NOT REQUIRE A DRS ORDER, BUT IT DOES REQUIRE CRITICAL THINKING |
| INDERPENDENT NURSING ACTION | TEACHING A PATIENT ABOUT THE SIDE EFFECTS OF A MED |
| DEPENDENT NURSING ACTION | REQUIRES A DRS ORDER |
| DEPENDENT NURSING ACTION | ADMINISTRATION OF A MED BECAUSE IT REQUIRES A RX |
| BACK MASSAGE | INDERPENDENT NURSING ACTION |
| ORDERING A HEATING PAD AND APPLYING IT TO A PATIENT | DEPENDENT NURSING ACTION |
| ASSISTING A SPEECH THERAPIST | INDERPENDENT NURSING ACTION |
| INDERPENDENT ACTIONS | COME FROM COLLABORATIVE CARE PLANNING |
| COLLABORATIVE TYPE OF PLAN OF CARE REFERRED TO AS A | CRITICAL PATHWAY, A CARE PATH, INTERDISCIPLINARY CARE MAP, STEP BY STEP APPROACH TO THE TOTAL CARE OF THE PATIENT |
| CRITICAL PATHWAY, MULTIDISCIPLINARY APPROACH TO PATIENT CARE | IS AN OUTGROWTH OF MANAGED CARE |
| THE NURSING CARE PLAN IS NOT PART OF THE PATIENTS CHART WHEN A CRITICAL PATHWAY IS USED | HOWEVER, THE NURSING PROCESS IS UTILIZED |
| EVALUATION IS | JUDGEMENT 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 WORKPLACE | HAS PARTICULAR REQUIREMENTS FOR THE WAY A PROCEDURE IS TO BE CARRIED OUT |
| EMPLOYEES AND STUDENTS | ARE EXPECTED TO PERFORM AT THE DESIGNATED STANDARD OF CARE LISTED IN THE PROCEDURE MANUAL |
| STUDENT NURSE IN CLINICALS | CARE ON RN'S TEACHERS LICENSE, SHOULD BE ABLE TO PERFORM ON LPN LEVEL |
| FOR EFFICIENT USE OF TIME | CONSIDER WHICH INTERVENTIONS CAN BE COMBINED, |
| BATHS AND BED MAKING | COMBINED |
| TIME IN THE ROOM GATHER MORE INFO, TEACHING PLAN | COMBINED |
| RANGE OF MOTION EXERCISES, BATH ROUTINE | COMBINED |
| THERE ARE SOME STANDARD STEPS THAT ARE ALWAYS FOLLOWED | WHEN PERFORMING A NURSING PROCEDURE, STEPS ARE BASED ON THE ANA STANDARDS OF CLINICAL PRACTICE, RIGHTS OF PATIENTS, SAFE NURSING PRACTICE |
| CLINICAL PATHWAY INCLUDES | ICD-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 NOTES | MUST INDICATE THAT THE NURSING CARE HAS BEEN CARRIED OUT |
| IF AN INTERVENTION ON THE CARE PLAN IS NOT MENTIONED IN CHARTING | IT IS CONSIDERED NOT DONE |
| IT IS WISE TO REVIEW THE NURSING CARE PLAN BEFORE BEGINNING CARE | TO HAVE A CLEAR IDEA OF ALL OF THE AREA THAT NEED WRITTEN DOCUMENTATION |
| DOCUMENTATION | RECORDING OF PERTINENT DATA ON THE CLINICAL RECORD |
| MOST HOSPITALS REQUIRE A | NOTATION ABOUT EACH PROBLEM OR NURSING DIAGNOSIS AT LEAST ONCE Q24H |
| AFTER IMPLEMENTING CARE FOR THE PATIENT | DOCUMENT THAT CARE ON THE PATIENTS CHART |
| ITEMS RECORDED | BATHING ON THE ACTIVITY FLOW SHEET |
| NEW PROBLEM ARISES | A NURSES NOTE IS REQUIRED TO DOCUMENT THE ASSESSMENT FINDINGS, NURSING DIAGNOSIS, AND THE PLAN TO CORRECT OR ALLEVIATE THE PROBLEM |
| THE SOONER CARE IS DOCUMENTED | THE BETTER |
| MOST HOSPITALS REQUIRE NURSES | DOCUMENT (CHART) ON EACH PATIENT Q2H |
| STANDARD STEPS FOR ALL NURSING PROCEDURES | AT THE BEGINNING OF THE PROCEDURE |
| STEP A: CHECK YOUR ORDER, COLLECT THE EQUIPMENT AND SUPPLIES, AND WASH YOUR HANDS | VERIFY 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 PATIENT | GREET, 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 EQUIPMENT | CLOSE 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 APPROPRIATE | PROTECT 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 PROTOCOL | MENTALLY 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 EQUIPMENT | MAKE 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 PLACES | MAKE 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 PROCEDURE | DOCUMENT 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 PROCESS | EVALUATION |
| ANA STANDARD VI | EVALUATION |
| EVALUATION | ONCE 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. |
| EVALUATION | IS 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 MET | THE NURSES NOTES MUST CONTAIN DATA TO SUPPORT THIS |
| NURSING CARE PLANS REVISE | AS 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 WHETHER | THERE IS A BETTER, MORE EFFICIENT INTERVENTION TO HELP THE PATIENT ACHIEVE THE EXPECTED OUTCOMES. |
| CONSTANT EVALUATION | IS AN INTEGRAL PART OF EVERY ASPECT OF NURSING |
| QUALITY MANAGEMENT | EVALUATION 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 |
| CGI | THIS PROGRAM IS USUALLY AGENCY WIDE, WORKING WITH NURSING AUDITS, COMPLIANCE WITH STANDARDS IN EVERY DEPT |
| NURSING AUDIT | IS EXAMINATION OF A SERIES OF PATIENT RECORDS TO DETERMINE IF NURSING CARE FOR THOSE PATIENTS MET PARTICULAR STANDARDS |
| EVERY HOSPITAL MUST PERFORM | MEDICAL AND NURSING AUDITS TO ACHIEVE AND MAINTAIN ACCREDITATION |
| PROCESS EVALUATION | LOOK AT THE ACTIVITIES OF THE NURSES AND WHAT THEY HAVE DONE TO ASSESS, PLAN, IMPLEMENT, AND EVALUATE NURSING CARE |
| PROCESS EVALUATION CRITERIA | ARE THE STANDARDS OF CLINICAL NURSING PRACTICE DEVELOPED BY THE ANA |
| PURPOSE OF EVALUATING NURSING CARE | IS TO ACHIEVE CONTINUOUS QUALITY IMPROVEMENT BY IDENTIFYING SPECIFIC AREAS THAT NEED CHANGES. |
| EVALUATION | IS NOT PERFORMED TO BLAME SOMEONE FOR CARELESSNESS, INCOMPETENCE OR INEFFICIENCY |
| NURSES ON A UNIT | OFTEN ROTATE AS THE QUALITY MANAGEMENT PERSON FOR THE UNIT SO THAT EVERYONE IS INVOLVED IN THE PROCESS |
| CONSTRUCTING A NURSING CARE PLAN | RN 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 |
| STUDENTS | ARE 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 PATIENT | OBTAIN 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 PROBLEMS | GROUP 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 PLAN | EVALUATE 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 |
