Chapter 19
Implementing Nursing Care
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Nursing Intervention


A nursing intervention is any treatment
based on clinical 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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
2
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
3
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
4
Standard Nursing Interventions




Clinical practice guidelines and protocols
Standing orders
NIC interventions
ANA Standards of Professional Practice
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
5
Protocols and Standing Orders
Guidelines and
Protocols
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
A preprinted document
containing orders for
the conduct of routine
therapies, monitoring
guidelines, and/or
diagnostic procedures for
specific patients with
identified clinical
problems
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
6
Implementation Process
Reassessing
the patient
Reviewing
and
revising the
existing
nursing
care plan
Organizing
resources
and care
delivery
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Anticipating
and
preventing
complications
7
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
8
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
9
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
10
Implementation Skills

Cognitive skills


Interpersonal skills


Application of critical thinking in the nursing
process
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
11
Direct Care vs. Indirect Care
Direct Care
Indirect Care
Treatments performed
through interactions with
patients
Treatments performed
away from the patient but
on behalf of the
patient or group of
patients
Examples:
-Medication
administration
-Insertion of an
intravenous (IV) infusion
-Counseling during a time
of grief
-Managing the patient’s
environment (e.g., safety
and infection control)
-Documentation
-Interdisciplinary
collaboration
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
12
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
13
Direct Care
Activities of Daily
Living
(ADLs)
Physical care
techniques
Instrumental
Activities of Daily
Living (IADLs)
Lifesaving measures
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
14
Direct Care (cont’d)
Counseling
Teaching
Controlling for adverse
reactions
Preventive measures
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
15
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 __________
_____________.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
16
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
17
Indirect Care

Communicating nursing interventions


Written or oral
Delegating, supervising, and evaluating the
work of other health care team members
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
18
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
19
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
20
Chapter 20
Evaluation
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
22
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
23
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
24
Standards for Evaluation

Nursing care helps patients
Resolve actual health problems
Prevent potential problems
Maintain a healthy state
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
25
Standards for Evaluation (cont’d)

American Nurses Association (ANA)


Defines standards
Competencies include:





Being systematic
Using criterion-based evaluation
Collaborating
Using ongoing assessment data to revise care
plan
Communicating results
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
26
Criterion-Based Standards
Criterion-based standards for evaluation are the
physiological, emotional, and behavioral
responses that are a
patient’s goals and expected outcomes.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
27
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
28
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
29
Collaborate and Evaluate
Effectiveness of Interventions





Collaborate with the
patient and family.
Use evaluative
measures.
Interpret and
summarize findings.
Document results.
Revise care plan.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
30
Objective Evaluation
1. Examine the outcome criteria.
2. Evaluate the patient’s actual response.
3. Compare the established outcome criteria with
the actual response.
4. Judge the degree of agreement between the
outcome criteria and the response.
5. If no or only partial agreement, what are the
barriers?
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
31
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
32
Revising a Care Plan

Discontinuing a care plan:
Has the goal been met?
Does the patient agree?
Document the discontinued plan.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
33
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
34
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
35
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
36
Quick Quiz!
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
37
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
38
Chapter 21
Managing Patient Care
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
40
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
41
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
42
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
43
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
44
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
45
Nursing Care Delivery Models
(cont’d)
Team Nursing
Total Patient Care
Primary Nursing
Case Management
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
46
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
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
47
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
48
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
49
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.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
50
Decision Making


Decentralized management means that
decision making occurs at the level of the
staff.
Encompasses




Responsibility: duties and activities an individual is
employed to perform
Autonomy: independent decisions about patient
care
Authority: legitimate power to give commands and
make final decisions specific to a given position
Accountability: answerable for the actions
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
51
Quick Quiz!
1. A travel nurse has taken an assignment at a
health care facility where nurses assume
responsibility for a caseload of patients over
a period of time. This type of nursing
exemplifies
A. Team nursing.
B. Primary nursing.
C. Functional nursing.
D. Decentralized management.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
52
Staff Involvement



Establishing nursing
practice or problemsolving committees or
professional shared
governance councils
Nurse/physician
collaborative practice
Interdisciplinary
collaboration


Staff communication
Staff education
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
53
Leadership Qualities
Dependabl
e
Competent
Problem Communicat
Solver
or
Evaluator
Delegator
Accountabl Coordinato
e
r
Educator
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
54
Leadership Skills
Clinical Care
Coordination
Team
Communication
Delegation
Knowledge
Building
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
55
Clinical Care Coordination






Clinical Decisions
Priority Setting
Organizational Skills
Use of Resources
Time Management
Evaluation
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
56
Priority Setting

Determine which patient’s needs should be
addressed first:

High priority: immediate threat to patient survival
or safety
 Intermediate priority: nonemergent, non–life
threatening
 Low priority: actual or potential problems may or
may not be directly related to patient’s illness or
disease
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
57
Case Study (cont’d)

Mrs. Sinclair’s surgery is scheduled for 1 PM.
She has never had surgery before and is very
nervous and moving restlessly in bed. She is
reluctant to talk, but her preoperative
checklist is not yet completed, and she needs
to be escorted to surgery in 30 minutes.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
58
Case Study (cont’d)

Mr. Timmons had abdominal surgery 2 days
ago for colon tumor removal. He has finished
his lunch and is ready for pain medication. He
is preparing to get out of bed to walk down
the hall.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
59
Case Study (cont’d)

Mr. Dodson has a postoperative wound
infection. His wet-to-dry abdominal dressing
needs to be changed, and he needs his next
dose of antibiotic.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
60
Case Study (cont’d)



Jennifer stays with Mrs. Sinclair to assess her
new symptoms and complete her
preoperative checklist. She sends a unit clerk
to check on Mr. Timmons.
Once Mrs. Sinclair’s checklist is completed,
she stops by Mr. Timmons’ room to assess
his pain and administer his medication.
She then verifies Mr. Dodson’s identification
and administers the antibiotic, and next
completes the dressing change.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
61
Organizational Skills






Perform tasks correctly.
Perform the correct tasks.
Utilize resources.
Manage time.
Evaluate outcomes.
Progress to an improved level of health.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
62
Time Management



Remain goal oriented.
Identify priorities.
Establish personal goals.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
63
Evaluate
Evaluate process.
Evaluate patient response.
Evaluate therapy efficacy.
Evaluate patient and expected outcomes.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
64
Case Study (cont’d)


When Jennifer assesses Mr. Timmons’ pain,
she discovers that his pain is still 8 out of 10
following Percodan 20 mg every 6 hours.
Patient-controlled analgesia (PCA) with
morphine was removed 4 hours ago.
She determines that his current pain
medication is insufficient to control his pain
and requests a change in his medication.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
65
Team Communication
Respect others’ ideas.
Share information.
Stay informed.
Strive to improve your communication.
Share expectations of communication.
Use structured communication techniques
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
66
Delegation



Transfers responsibility while remaining
accountable for outcomes
Requires knowing which skills are
transferable
Results in improved quality of patient care,
improved efficacy, increased productivity, and
an empowered staff
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
67
The Five Rights of Delegation





Right Task
Right Circumstance
Right Person
Right Direction
Right Supervision
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
68
Steps to Effective Delegation



Assess the knowledge and skills of the
delegatee.
Match tasks to the delegatee’s skills.
Communicate clearly:



Task, outcome, time
Listen attentively.
Provide feedback.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
69
Quick Quiz!
2. A newly graduated nurse is assigned to care for a
team consisting of herself and a certified nursing
assistant. When delegating skills, she needs to
A. Assign only bed-making and feeding skills.
B. Assess the knowledge of the certified nursing
assistant.
C. Remind the staff member that she is working under
the license of the RN.
D. Allow the staff member to perform only skills that the
RN is able to teach certified nursing assistants to
perform.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
70
Knowledge Building




Remain competent.
Pursue lifelong learning.
Share the knowledge.
To become a leader, actively pursue learning
opportunities, both formal and informal, and
learn to share knowledge with the
professional colleagues you encounter.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
71