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this follows assessment, nursing diagnosis and planning (ANPIE)
the phase of the nursing process in which nursing interventions (or orders) are carried out
change-of-shift report should give clues as to the priority of each action to be implemented
Always think of time flexible and time fixed tasks when prioritizing
what may need to happen if pt's condition becomes more acute?
priorities of care may need to be altered
what is a time flexible task?
can be done at any time
what is a time-fixed task?
must be done at a set time
what should you do before carrying out specific interventions listed on care plan
reason for the intervention
rationale for the intervention
usual standard of care
what is interdisciplinary care?
otherwise called clinical pathways or care map
-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
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
Who performs invasive or sterile procedures
who performs exercise interventions?
nursing assistants, physical therapy aids or restorative aids
who administers medications?
LPNs or nursing assistant with certification in medication administration
Who implements interventions in home health?
the family may be implementing the interventions
the nurse making home visits teaches familt to:
perform range-of-motion exercises
the nurse performs any invasive procedures or procedures where strict sterility is mandatory
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
each intervention MUST be documented in patients chart
when documenting you are indicating that care plan is carried out
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
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
What if goals are not being met?
plan must be revised
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
An audit can be done without ever looking at a pt. should be that clear and well documented
How often should care plans be reviewed?
once every 24 hrs
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