N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide specific in identifying who can do the treatments and how the procedures must be done. • Protocols as defined by the healthcare organization: Many organizations have defined protocols that can be used in very specific instances. These protocols may be called standing orders and define specific interventions that can be used when a patient meets certain conditions. For example, a hospital might have an “upper GI prep” protocol that defines what medications, diets, etc. are expected for a patient who will be undergoing an upper gastrointestinal test. This protocol allows the nurse to implement any measure defined in the protocol. • The Nursing Interventions Classification (NIC): This is a standardized classification of patient interventions that was developed in the beginning of 1991 at the University of Iowa, and has been recognized by the American Nurses’ Association as one of the approved nursing standard languages. This classification can be used in conjunction with the NANDA Taxonomy of Nursing Diagnoses and the Nursing Outcomes Classification (NOC). Nursing interventions can be classified as: • Independent: Independent interventions are those that the nurse can perform autonomously and without a physician’s order. For example, providing oral care for a patient who is unresponsive is an intervention. It promotes health maintenance and does not require an order. • Interdependent: Interdependent interventions (also called collaborative interventions) are those that are implemented with other health care providers. For example, a physical therapist may teach a patient some exercises that the nurse can help the patient perform later. • Dependent: Dependent interventions are those that must be ordered by a provider with legal authority to write orders. For example, a provider with prescriptive authority must write an order for the patient’s medication. A nurse cannot legally give a medication that has not been ordered; however, a nurse must always use professional judgment when following any order. Development of the Patient’s Plan of Care At this point, the nurse will begin to develop the patient’s plan of care using the nursing diagnoses, goals, expected outcomes, and nursing interventions that have been identified based on the assessment of the patient. As with all other aspects of the nursing process, the plan of care is continuously updated based on any new data that may have developed about the patient. Components of a care plan:

Component

Activity

Example

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