Chapter 6.txt

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Chapter 6.txt
2011-11-05 14:05:03

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  1. Implementation
    Observing, reporting and recording significant changes which require intervention or different goals; applying nursing knowledge; assisting patient and family with ADLs; carrying out therapeutic regimens
  2. Evaluation
    relevancy of current goals; involvement of recipients of care; quality of the nursing action; reordering of priorities or new goal setting
  3. Before carrying out specific interventions listed on the plan of care
    identify reason for intervention, rationale for intervention, usual standard of care, expected outcome, and potential dangers
  4. Independent nursing action
    does not require a dr order, but does need critical thinking and nursing judgment
  5. Dependent nursing action
    requires a dr order (administering meds)
  6. Interdependent nursing action
    those that come from collaborative care planning (helping pt with speech exercises)
  7. Clinical pathway/care map
    step by step approach to the total care of the patient; also called interdisciplinary care plan or collaborative care plan
  8. When an interdisciplinary care plan is used,
    the nursing care plan is not part of the patient�s chart although the nursing process is still used
  9. Most hospitals require that some note be made about each problem or nursing diagnosis at least once every
    24 hours
  10. Long term care require notes written every
    7 days or when patient�s condition changes
  11. Many hospitals require that the nurse chart
    every 2 hours
  12. Nursing audit is
    examination of a series of patient records to determine if nursing care for those patient met particular standards and particular outcomes; usually performed on patients who has been discharged
  13. Once the interventions are carried out,
    you must determine whether they are effective in helping the patient reach the expected outcomes