Implementation
def; nursing action based on clinical judgment and knowledge.
during implementation;
the nurse carries out the plan of care and document interventions.
it occurs;
after the nurse develops the plan of care.
it consists of;
performing patient care interventions and documenting the interventions in the
patient’s medical record (repositioning, administered prescribe meds)
purpose;
to promotes achievement of outcomes.
it begins;
after assessment and the 2 others
scope of practice
defines inter. that is qualified to practice and competent to perform.
clinical practice guidelines (CPG)
documentation;
should align with regulatory requirements
provide info for decision making.
intervention categorization;
1. purpose
can be initiated by any health care team
it consists of prob. based _ manage existing prob. (higher priority)
prevention based_ prevent prob.
2. Responsible for Initiating and Conducting Interventions
consists of prob. and prevention-based, may or may not involved personal
contact
3. Personal Contact with Patient;
may be initiated by any member of the health care team
Direct-Care Interventions
Direct-care interventions take place through personal contact with the patient.
Direct-care interventions include reassessment, activities of daily living (ADLs),
physical care, informal counseling, and patient education
There are two types of physical care interventions:
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Invasive procedures, such as starting an intravenous (IV) line or inserting a
catheter.
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Noninvasive actions, such as administering oral medications and
repositioning.
Indirect-Care Interventions
Indirect-care interventions are performed on behalf of the patient, but they do
not involve direct patient contact.
communication
referrals
research
advocacy
delegation
Take actions;
after generating solutions which is where the nurse answered questions of what
the nurses can do to address the hypotheses by identify potential nursing
interventions for the patient’s problems
the type of interventions;
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direct
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nurse-initiated
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independent
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evidence-based practice
steps
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recognize cues;
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analyze cue;
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prioritize hypotheses;
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generate solutions;
1. review all intervention
2. recognize which need immediatly
3. consider all consequence
4. determine probability of consequences
The nurse incorporates professional and organizational standards of clinical
practice when taking action to address prioritized needs.
Set of 3–5 evidence-based interventions that improve patient outcomes
care bundles
standing orders
Preestablished set of health care provider prescriptions used to direct patient
care
scope of practice
Outlines the duties that all nurses should be able to perform competently
clinical practice guidlelines
Recommendations facilitating the application of current evidence into practice
Considers patient preferences, values, and beliefs
Attitudes involve considering how patient preferences, values, and beliefs
influence decision-making related to taking action
List in order steps the nurse can use to determine how to take action to address
prioritized patient needs.
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Review all possible nursing interventions for the patient problem
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Recognize which interventions are needed immediately
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Consider all potential consequences associated with each possible nursing
action
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Determine the probability of potential consequences
Incorporates organizational standards of practice
The nurse incorporates professional and organizational standards of clinical
practice when taking action to address prioritized needs.
When taking action to address patient needs, which rationales support the
importance of ongoing assessment of the patient?
Select all that apply.
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Accuracy of the plan of care is important for positive outcomes.
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Priority interventions can vary because of changing patient conditions.
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Life-threatening conditions requiring immediate attention can be identified.
EVALUATION
Evaluation is the last step in the nursing process and is essential for determining
the effectiveness of nursing care
The evaluation process begins by asking, “Has the patient’s goal been met?”
1. When a goal is met, the nurse decides if the goal should be continued or
discontinued, based on patient preference and the nurse’s clinical judgment.
2. When a goal is partially met, the nurse tries to figure out why and revises
the plan of care. The nurse might modify the goal or continue the original
goal with a new time frame.
3. When a goal is unmet, the nurse should consider underlying causes as to
why the goal was not met to decide whether to continue, revise, or
discontinue the goal. As nurses evaluate patient outcomes, higher-priority
goals sometimes emerge due to changes in the patient’s condition.
When determining which actions to take during step 5 of the Clinical Judgment
Measurement Model, which activities enable the nurse to validate the accuracy
and appropriateness of the plan of care?
Select all that apply.
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Reassessing the patient
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Anticipating complications
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Identifying urgent interventions
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Revising the plan of care if needed
Which aspects of patient care may influence the revision of the nurse’s
anticipated intervention priorities?
Select all that apply.
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Changing patient conditions
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Ongoing patient assessment
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Potential patient complications
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Increased experience of the nurse
Evaluation statements include evidence of factors contributing to the goal being
met, partially met, or unmet. Evaluation statements also include revisions
needed in the plan of care.
Process of quality improvement
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Review data about nursing care.
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Determine factors contributing to positive patient results.
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Make changes in nursing practice.
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ILLNESS PREVENTION
Assessment is the first step of the nursing process and involves the organized
collection of patient data/cues from a variety of sources.
The second step of the nursing process is analysis. During this phase of the
nursing process, the nurse analyzes, organizes, and clusters patient cues/data
to identify actual or potential patient problems. The two primary nursing tasks
during the analysis phase are as follows:
Recognize Cues and form diagnoses
Form Diagnostic Conclusions
Planning patient care is the third step of the nursing process. Following
identification of nursing diagnoses and collaborative problems, nurses must
prioritize the nursing diagnoses, identify goals with specific outcomes, and
select appropriate interventions.
Implementation is the fourth step of the nursing process, and it involves initiation
of appropriate interventions designed to meet the unique needs of each patient.
Nurses collaborate with interdisciplinary health care team members to provide
patient care through interventions that promote, maintain, or restore health.
Implementation involves performing nursing care, such as completing an
assessment or administering a medication, and documenting the interventions
implemented.
steps to prepare for implementation by completing five preparatory activities:
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Reassess the patient.
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Review and revise the existing plan of care.
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Organize resources and care delivery.
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Anticipate and prevent complications.
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Implement nursing interventions.
Which characteristics of the nursing process allow the nurse to effectively apply
critical thinking to patient care?
It is organized.
It allows nurses to apply knowledge.
It is outcome-oriented.
It requires nurses to think analytically.
It incorporates an interprofessional team.
Which questions are critical for the nurse to ask during each step in the nursing
process?
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Is collected data thorough and accurate?
Could interventions affect the patient negatively?
Are all underlying factors addressed in the plan of care?
Which phrases describe the role of the International Classification for Nursing
Practice (ICNP) in the nursing process?
Provides a standardized nursing language
Identifies common labels for nursing diagnoses
Provides point-of-care documentation for clinical activity
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During which step of the nursing process would the nurse prioritize nursing
diagnoses? planning
Which step of the nursing process involves carrying out nursing actions
designed to meet a patient’s unique needs? implementation
Which statements reflect the nurse’s role during the implementation step of the
nursing process?
Be accountable for safe practice.
Perform the steps of intervention accurately.
Understand why an intervention is planned.
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