Chapter 19

1. Chapter 19 Implementing Nursing Care

2. Nursing Intervention • A nursing intervention is any treatment based onclinical judgment and knowledge that a nurse performs to enhance patient outcomes. • Interventions include direct and indirect care measures aimed at individuals, families, and/or the community.

3. Case Study • Miranda is a nursing student who is assigned to Mr. Bagley. Mr. Bagley is a 52 y/o Asian male admitted to the medical-surgical unit for management of tuberculosis. Mr. Bagley travels internationally because of his executive position with a global company and most likely contracted tuberculosis during his travels. • Mr. Bagley’s current symptoms are shortness of breath, night sweats, muscle pain, fatigue, and a productive cough. Miranda reviews Mr. Bagley’s plan of care to determine which interventions are to be implemented first.

4. Critical Thinking in Implementation • Review the set of all possible nursing interventions. • Review all possible consequences associated with each possible nursing action. • Determine the probability of all possible consequences. • Make a judgment of the value of that consequence to the patient.

5. Standard Nursing Interventions • Clinical practice guidelines and protocols • Standing orders • NIC interventions • ANA Standards of Professional Practice

6. Protocols and Standing Orders

7. Implementation Process

8. Anticipate and Prevent Complications • Identify risks to the patient. • Adapt interventions to the situation. • Evaluate the relative benefit of a treatment vs. the risk. • Initiate risk prevention measures.

9. Modification of an Existing Written Care Plan • Revise data assessment. • Revise the nursing diagnoses. • Revise specific interventions. • Determine how to evaluate whether you have achieved outcomes.

10. Quick Quiz! 1. Nurse-initiated interventions are A. Determined by state Nurse Practice Acts. B. Supervised by the entire health care team. C. Made in concert with the plan of care initiated by the physician. D. Developed after interventions for the recent medical diagnoses are evaluated.

11. Implementation Skills • Cognitive skills • Application of critical thinking in the nursing process • Interpersonal skills • Developing a trusting relationship, expressing a level of caring, and communicating clearly with a patient and his or her family • Psychomotor skills • Integration of cognitive and motor activities

12. Direct Care vs. Indirect Care

13. Case Study (cont’d) • Miranda searches the hospital’s database for additional information on tuberculosis. • True or False: A clinical practice guideline is a collection of institutional policies that assist nurses, physicians, and other health care providers in making decisions about appropriate health care for specific clinical situations, such as the management of tuberculosis.

14. Direct Care

15. Direct Care (cont’d)

16. Case Study (cont’d) • Mr. Bagley’s plan of care calls for oxygen therapy to improve his respiratory status. • A preprinted document that contains orders for the conduct of routine therapies, such as oxygen therapy, is referred to as a __________ _____________.

17. Quick Quiz! 2. You are writing a care plan for a newly admitted patient. Which one of these outcome statements is written correctly? A. The patient will eat 80% of all meals. B. The nursing assistant will set the patient up for a bath every day. C. The patient will have improved airway clearance by June 5. D. The patient will identify the need to increase dietary intake of fiber by June 5.

18. Indirect Care • Communicating nursing interventions • Written or oral • Delegating, supervising, and evaluating the work of other health care team members

19. Case Study (cont’d) • Mr. Bagley is placed on Isolation Precautions. • Isolation Precautions as a treatment intervention are an example of which type of care? A. Direct B. Indirect C. Prevention D. Safety

20. Achieving Patient Goals • Nurses implement care to meet patient goals. • At times, multiple interventions may be needed. • Priorities help nurses to anticipate and sequence nursing interventions. • Patient adherence means that patients and families invest time in carrying out required treatments.

21. Chapter 20 Evaluation

22. Critical Thinking and Evaluation • Evaluation is an ongoing process. • If outcomes are met, patient goals are met. • Positive evaluations occur when nurses meet desired outcomes. • Positive evaluations lead nurses to conclude that interventions were successful.

23. Case Study • Miyoko is a nursing student assigned to Mr. Mashoud, a 48-year-old Arab male admitted to the hospital with kidney stones. • Upon Mr. Mashoud’s admission to the emergency department (ED) this morning, he was experiencing excruciating pain. • The treatment plan for Mr. Mashoud includes keeping him in the hospital until he passes the stones and adjusting his pain medication as needed.

24. Case Study (cont’d) • Miyoko evaluates Mr. Mashoud’s response to the medication therapy to update his care plan. Miyoko assesses Mr. Mashoud’s pain before NSAID administration and then approximately one hour after administration. • Miyoko knows that evaluation is an ____________ process that occurs whenever contact with a patient occurs.

25. Standards for Evaluation • Nursing care helps patients

26. Standards for Evaluation (cont’d) • American Nurses Association (ANA) • Defines standards • Competencies include: • Being systematic • Using criterion-based evaluation • Collaborating • Using ongoing assessmentdata to revise care plan • Communicating results

27. Criterion-Based Standards

28. Criterion-Based Evaluation • Goal = Expected behavior or response that indicates resolution of a nursing diagnosis or maintenance of a healthy state • Expected outcome = End result that is measurable, desirable, and observable and translates into observable patient behaviors • Nursing-sensitive outcome

29. Case Study (cont’d) Miyoko determines the patient outcomes for Mr. Mashoud based on his reaction to the medication regimen. • Which of the following is an end result that translates into observable patient behaviors that are measurable and desirable? A. Unexpected outcome B. Expected outcome C. Sensitive outcome D. Accomplished outcome

30. Collaborate and Evaluate Effectiveness of Interventions • Collaborate with the patient and family. • Use evaluative measures. • Interpret and summarize findings. • Document results. • Revise care plan.

31. Objective Evaluation

32. Case Study (cont’d) Miyoko follows which steps to objectively evaluate the degree of success in achieving outcomes of care for Mr. Mashoud? (Select all that apply.) A. Identify the exact desired patient behavior. B. Evaluate the patient’s actual behavior. C. Compare the outcome criteria with the actual behavior. D. Assess the desired behavior and anticipated outcome. E. Judge the degree of agreement between the outcome criteria and the actual behavior.

33. Revising a Care Plan • Discontinuing a care plan:

34. Quick Quiz! 1. Your patient has met the goals set for improvement of ambulatory status. You would now A. Modify the care plan. B. Discontinue the care plan. C. Create a new nursing diagnosis that states goals have been met. D. Reassess the patient’s response to care and evaluate the implementation step of the nursing process.

35. Revising a Care Plan (cont’d) • Modifying a care plan: • Reassessment • Redefining diagnoses • Goals and expected outcomes • It sometimes becomes necessary to collect evaluative measures over time to determine whether a pattern of change exists.

36. Revising a Care Plan (cont’d) • Modifying a care plan: Interventions • Appropriateness of the intervention • Based on the standard of care • Correct application of the intervention • A patient’s nursing diagnoses, priorities, and interventions sometimes change as a result of evaluation.

37. 2. You have finished with several nursing interventions. To evaluate interventions, you need to examine the: A. Appropriateness of the interventions and the correct application of the implementation process. B. Nursing diagnoses to ensure that they are not medical diagnoses. C. Care planning process for errors in other health care team members’ judgments D. Interventions of each nurse to enable the nurse manager to correctly evaluate performance. Quick Quiz!

38. Revising a Care Plan (cont’d) • Modifying a care plan: • Unmet patient needs • When a goal is not met, no matter what the reason, repeat the entire nursing process sequence for that nursing diagnosis to identify necessary changes to the plan. • By consistently incorporating evaluation into practice, you minimize errors and ensure that the patient’s plan of care is appropriate and relevant.

39. Chapter 21 Managing Patient Care

40. Entry Level Competencies • The National Council of State Boards of Nursing (NCSBN) identified competencies that registered nurses (RNs) and licensed practical/ vocational nurses need on entry to practice. Three of these are: • Demonstrate nursing knowledge and display confidence in knowledge base. • Demonstrate knowledge of roles, responsibilities, and functions of a nurse. • Recognize own limitations and see support of validation of decisions as needed.

41. Empowered Nursing Team • Includes nurse executive, nurse manager, and nursing staff • Nurse executive possesses many roles: • Ethical leader • Business leader • Quality of care promoter • Cost-effectiveness promoter

42. Empowered Nursing Team (cont’d) • Philosophy of care • Professional nursing staff’s values and concerns for the way they view and care for patients • Selection of nursing care delivery model that supports professional nursing practice • Selection of a management structure that supports professional nursing practice

43. Magnet Recognition • Magnet hospitals typically have clinical promotion systems and research and evidence-based practice. • Nurses have professional autonomy over their practice and control over the practice environment. • Magnet hospitals empower the nursing team to make changes and be innovative. • This results in a strong collaborative relationship among team members and improved patient quality of care outcomes.

44. Case Study • Jennifer is a nursing student who is assigned the following three patients: • Mrs. Sinclair, who is scheduled for surgery to repair a fractured right hip • Mr. Timmons, who has finished lunch and is ready for pain medication • Mr. Dodson, who has a postoperative wound infection and is due for antibiotic medication

45. Nursing Care Delivery Model • Assists nurses in achieving desirable outcomes for their patients • Results in success via the following factors: • Decision-making authority for nurses • Effective methods of communicating with colleagues

46. Nursing Care Delivery Models (cont’d)

47. Team Nursing • Collaborative care style that encourages each member of team to work with and help the other members • Hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members • Decision making occurs at clinical level

48. Total Patient Care • Registered nurse works directly with patient, family, and health care team members. • RN is responsible for patients during shift of care, although care can be delegated. • Approach may not be cost-effective owing to high number of registered nurses needed. • Patient satisfaction is high.

49. Primary Nursing • One primary registered nurse assumes responsibility for caseload. • Communication is lateral from nurse to nurse and from caregiver to caregiver. • Flexible model uses a variety of staffing levels and mixes. • RN works with a limited number of patients.

50. Case Management • Collaborative process of assessing, planning, facilitating, and advocating for options and services to meet an individual’s health needs • Clinicians oversee the management of patients with specific, complex health problems and are usually held accountable for some standard of cost management and quality. • Often the case manager is an advanced practice nurse, who helps improve patient outcomes via specific interventions.