Chapter 19 Implementing Nursing Care Copyright 2013 2009

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 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 Ø Interpersonal skills Ø 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 Ø 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. Ø 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. Ø 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 Ø 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 as a treatment intervention are an example of which type of care? A. Direct B. Indirect C. Prevention D. Safety Ø 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 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. Ø 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) Ø Defines standards Competencies include: Ø Ø Ø 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 Ø 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 Ø 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: Ø Ø Ø 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 Ø Correct application of the intervention Ø 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: Ø 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. Ø Demonstrate knowledge of roles, responsibilities, and functions of a nurse. Ø Recognize own limitations and see support of validation of decisions as needed. Ø 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: Ø Ø 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 Ø Selection of nursing care delivery model that supports professional nursing practice Ø Selection of a management structure that supports professional nursing practice Ø 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 Ø Mr. Timmons, who has finished lunch and is ready for pain medication Ø Mr. Dodson, who has a postoperative wound infection and is due for antibiotic medication Ø 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: Ø Ø 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 Ø Autonomy: independent decisions about patient care Ø Authority: legitimate power to give commands and make final decisions specific to a given position Ø Accountability: answerable for the actions Ø 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 Ø Intermediate priority: nonemergent, non–life threatening Ø Low priority: actual or potential problems may or may not be directly related to patient’s illness or disease Ø 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 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: Ø 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