LPN Fundamentals.txt

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LPN Fundamentals.txt
2012-01-12 19:19:35

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  1. Implementation
    • this follows assessment, nursing diagnosis and planning (ANPIE)
    • the phase of the nursing process in which nursing interventions (or orders) are carried out
  2. change-of-shift report should give clues as to the priority of each action to be implemented
  3. Always think of time flexible and time fixed tasks when prioritizing
  4. what may need to happen if pt's condition becomes more acute?
    priorities of care may need to be altered
  5. what is a time flexible task?
    can be done at any time
  6. what is a time-fixed task?
    must be done at a set time
  7. what should you do before carrying out specific interventions listed on care plan
    • identify:
    • reason for the intervention
    • rationale for the intervention
    • usual standard of care
    • expected outcome
    • potential dangers
  8. what is interdisciplinary care?
    • otherwise called clinical pathways or care map
    • it is
    • -a interdisciplinary approach to managed pt care
    • an outgrowth of maned care
    • still uses nursing process
    • usually standardized to a medical diagnosis and customized to each patient
    • care plan is not a part of pt chart when interdisciplinary care plan is used
    • *ALL disciplines provide input
    • started to use them to keep cost down & decrease recovery time
  9. Implementing care
    • employees and students expected to perform at standard of care listed in procedure manual
    • for efficient time use consider which interventions for a pt can be combined
    • you need to know if there is a specific standard to providing the care you are about to give
  10. Who performs invasive or sterile procedures
    the nurse
  11. who performs exercise interventions?
    nursing assistants, physical therapy aids or restorative aids
  12. who administers medications?
    LPNs or nursing assistant with certification in medication administration
  13. Who implements interventions in home health?
    • the family may be implementing the interventions
    • the nurse making home visits teaches familt to:
    • administer medications
    • change dressings
    • perform range-of-motion exercises
    • perform treatments
    • the nurse performs any invasive procedures or procedures where strict sterility is mandatory
  14. Standard Steps to remember when planning to do a procedure
    • mentally review procedure-if you can't remember the steps you better go look it up
    • check order, collect equipment, wash hands (always make sure there is a drs order on the chart for the procedure)
    • identify and prepare pt
  15. Documentation
    • each intervention MUST be documented in patients chart
    • when documenting you are indicating that care plan is carried out
  16. Evaluation
    • once interventions have been implemented they must be evaluated fo effectiveness in reaching the pt goals or outcomes
    • patient should provide feedback about whether the expected outcome has been met
  17. What do you do if goals are met?
    if goals are reached and problem resolved, it is evaluated, signed off in the nurses notes as met and removed from care plan
  18. What if goals are not being met?
    plan must be revised
  19. What is quality improvement?
    • ourcome-based quality improvement to determine whether outcomes are effective
    • agency-wide evaluation of care delivered by all departments against standards set for each department
    • audits at predetermined intervals
    • evaluation goal:continuous quality improvement
  20. An audit can be done without ever looking at a pt. should be that clear and well documented
  21. How often should care plans be reviewed?
    once every 24 hrs
  22. constructing a nursing care plan
    • 1. collect patient data for database
    • 2. analyze the database for potntial problems
    • 3. choose appropriate nursing diagnosis
    • 4. rank the nursing diagnosis in order of priority
    • 5. plan the care by defining goals and writing expected outcomes
    • 6. plan nursing care by choosing appropriate nursing interventions
    • 7. implement the nursing interventions
    • 8. evaluate outcomes of each nursing intervention:determine whether progress toward achieving expected outcomes has been made