Nursing 104

N104: Essentials of Nursing Care - Health Safety Study Guide 2nd Edition 11/6/2018

This study guide is subject to copyright.

Acknowledgements We would like to thank the authors for their patience, support, and expertise in contributing to this study guide, and Christina Wulff for her invaluable efforts in reading and editing the text. We would also like to thank those at Achieve whose hard work and dedication to fulfilling this project did not go unnoticed. Lastly, we would like to thank the Achieve students who have contributed to the growth of these materials over the years.

Copyright © 2018 by Achieve All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review. Printed in the United States of America First Printing, 2012 Achieve PO Box 10188 #29831 Newark, NJ 07101-3188 Tel: 888.900.8380 Visit the Achieve website at http://www.achievetestprep.com/student

N104: Essentials of Nursing Care – Health Safety Study Guide

Table of Contents Chapter One: The Nursing Process .............................................................................................................6 1.1 Assessment ............................................................................................................................................................ 7 Purpose of the Assessment ....................................................................................................................................................................7 Types of Assessments ...............................................................................................................................................................................7 Types of Assessment Data ......................................................................................................................................................................8 Components of the Assessment...........................................................................................................................................................8 1.2 Analysis and Diagnosis .....................................................................................................................................11 Analysis of the Data................................................................................................................................................................................. 11 Problem Identification........................................................................................................................................................................... 11 Nursing Diagnosis Overview.............................................................................................................................................................. 11 Developing the Nursing Diagnoses List........................................................................................................................................ 12 1.3 Planning................................................................................................................................................................13 Nursing Diagnosis Prioritization...................................................................................................................................................... 13 Identification of Goals or Expected Outcomes .......................................................................................................................... 14 Identification of Nursing Interventions........................................................................................................................................ 14 Development of the Patient’s Plan of Care.................................................................................................................................. 15 1.4 Implementation/Intervention........................................................................................................................16 1.5 Evaluation ............................................................................................................................................................17 1.6 Conclusion............................................................................................................................................................18 1.7 Chapter One Practice Exam.............................................................................................................................19 Chapter Two: The Physical Examination ............................................................................................... 21 2.1 Skin.........................................................................................................................................................................21 2.2 Neurological.........................................................................................................................................................22 2.3 Musculoskeletal..................................................................................................................................................28 2.4 Ears.........................................................................................................................................................................31 2.5 Eyes ........................................................................................................................................................................32 2.6 Nose........................................................................................................................................................................35 2.7 Mouth/Throat .....................................................................................................................................................36 2.8 Neck........................................................................................................................................................................38 2.9 Chest/Thorax.......................................................................................................................................................40 2.10 Breasts and Lymph Nodes .............................................................................................................................41 2.11 Cardiac/Cardiovascular.................................................................................................................................43 2.12 Abdomen ............................................................................................................................................................44 2.13 Extremities ........................................................................................................................................................46 2.14 Chapter Two Practice Exam..........................................................................................................................48 Chapter Three: Communication and Learning Issues ........................................................................ 50 3.1 Communication...................................................................................................................................................50 Communication Process ....................................................................................................................................................................... 50 Types of Communication ..................................................................................................................................................................... 51 Therapeutic Communication ............................................................................................................................................................. 52 Communication Barriers...................................................................................................................................................................... 53 3.2 Teaching and Learning .....................................................................................................................................54

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N104: Essentials of Nursing Care – Health Safety Study Guide of 134 Teaching Principles................................................................................................................................................................................. 55 Learning Principles ................................................................................................................................................................................. 56 Therapeutic Nurse/Patient Relationship .................................................................................................................................... 56 3.3 Factors Influencing Communication and Learning...................................................................................57 3.4 The Nursing Process and Communication Issues......................................................................................58 3.5 Chapter Three Practice Exam .........................................................................................................................60 Chapter Four: Health and Illness.............................................................................................................. 62 4.1 Models of Health and Illness ...........................................................................................................................62 Travis’s Illness/Wellness Continuum............................................................................................................................................ 62 Dunn’s High-Level Wellness............................................................................................................................................................... 63 Rosenstock’s and Becker’s Health Belief Model....................................................................................................................... 63 Leavell and Clark’s Agent-Host-Environment Model ............................................................................................................ 64 4.2 Stress and Adaptation.......................................................................................................................................65 Types and Manifestations of Stressors ......................................................................................................................................... 66 Anxiety........................................................................................................................................................................................................... 66 4.3 Health Maintenance...........................................................................................................................................67 Factors Influencing Health Maintenance..................................................................................................................................... 67 4.4 The Nursing Process in Health and Illness..................................................................................................69 4.5 Chapter Four Practice Exam............................................................................................................................73 Chapter Five: Pediatric Care...................................................................................................................... 75 5.1 Family Theories ..................................................................................................................................................75 5.2 The Role of the Pediatric Nurse......................................................................................................................76 5.3 Factors Influencing Pediatric Care ................................................................................................................76 5.4 The Nursing Process in Pediatric Care.........................................................................................................78 5.5 Chapter Five Practice Exam.............................................................................................................................82 Chapter Six: Biological Concerns.............................................................................................................. 84 6.1 Chain of Infection ...............................................................................................................................................84 6.2 Asepsis...................................................................................................................................................................86 Medical Asepsis......................................................................................................................................................................................... 86 Surgical Asepsis ........................................................................................................................................................................................ 88 6.3 Body Defense Mechanisms ..............................................................................................................................90 Specific Immune Responses ............................................................................................................................................................... 90 Nonspecific Immune Defense ............................................................................................................................................................ 90 Stages in the Infectious Process ....................................................................................................................................................... 91 Inflammation.............................................................................................................................................................................................. 91 6.4 Wounds .................................................................................................................................................................91 Types of Skin Lesions............................................................................................................................................................................. 92 How Wounds Heal ................................................................................................................................................................................... 93 Wound Dressings ..................................................................................................................................................................................... 94 Wound Healing Complications.......................................................................................................................................................... 94 6.5 Biological Weapons ...........................................................................................................................................95 6.6 Factors Influencing Biological Safety............................................................................................................96 6.7 The Nursing Process and Biological Safety .................................................................................................97 6.8 Chapter Six Practice Exam............................................................................................................................ 101 ©2018 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N104: Essentials of Nursing Care – Health Safety Study Guide Chapter Seven: Environmental Concerns ............................................................................................103 7.1 Environmental Safety Hazards.................................................................................................................... 103 7.2 Factors Affecting Environmental Safety.................................................................................................... 106 7.3 The Nursing Process and Environmental Concerns .............................................................................. 107 7.4 Chapter Seven Practice Exam....................................................................................................................... 110 Chapter Eight: Medication Safety ...........................................................................................................112 8.1 Principles of Medication Safety................................................................................................................... 112 Medication Forms and Preparations........................................................................................................................................... 112 Classification of Medications........................................................................................................................................................... 113 Pharmacokinetics.................................................................................................................................................................................. 113 Drug Actions and Effects ................................................................................................................................................................... 114 8.2 Medication Administration .......................................................................................................................... 115 "Five-Plus-Five" Rights of Administration............................................................................................................................... 115 Tips for Safe Medication Administration.................................................................................................................................. 117 8.3 Medication Measurement, Conversion, and Calculation...................................................................... 118 Systems of Measurement .................................................................................................................................................................. 118 Dosage Conversions............................................................................................................................................................................. 119 Dosage Calculations ............................................................................................................................................................................. 119 Intravenous Flow Rates..................................................................................................................................................................... 120 8.4 Factors Affecting Medication Safety........................................................................................................... 121 8.5 The Nursing Process and Medication Safety............................................................................................ 123 8.6 Chapter Eight Practice Exam........................................................................................................................ 125 Answer Keys.................................................................................................................................................127

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N104: Essentials of Nursing Care – Health Safety Study Guide Chapter One: The Nursing Process The nursing process is the scientific process that provides the basis for all nursing care. It is delivered by the nurse to the patient. Because the nursing process is closely tied to the scientific method, it provides a firm foundation for the delivery of a patient’s care. It is important to note that the nursing process: • Must be patient centered: Any plan of care is developed with the patient’s needs and problems as the central focus. • Is systematic and rational: The goal of the nursing process is to identify the patient’s healthcare status, build goals, and develop a plan around that status while delivering nursing interventions to move the patient towards the desiredgoal. • Is cyclical in nature: The nursing process consists of five steps that follow a logical sequence. The steps are interrelated and dependent on each other; therefore, the process only ends when the patient achieves the desired goal. The five steps in the nursing process are: assessment, diagnosis or analysis, planning, implementation or intervention, and evaluation. • Requires critical thinking skills: Within this defined process, the nurse has the freedom to solve the problem, make decisions, and utilize creative thinking to alter the nursing treatment course for the patient. As the condition of the patient changes, the patient’s plan must also change quickly. • Requires collaboration with the patient, the patient’s family, and other healthcare providers: Because the process allows immediate “course correction”, when the patient’s condition changes everyone on the team must be involved. The patient is the center of care and must be involved in the planning. The patient’s family will be involved, if that is the patient’s wish. The healthcare team, physicians, nurses, aides, therapists, and case managers, must work together to ensure that the plan makes sense and is moving the patient towards the agreed upongoals. • Is supported by the American Nurses Association and The Joint Commission: The goal is to provide a framework for nursing care of the patient in anyenvironment. • Must be based on a framework of ethical and legal standards: Care should follow the standards as defined by the Nurse Practice Act in each state. In order to apply the nursing process to the care of patients, the nurse must develop several core competencies. These include: • Interpersonal and communication skills that will allow the nurse to listen to the patient, family, and other team members, while being able to distill the information obtained and communicate the plans to all the members of the team. • Technical skills that will allow the nurse to perform nursing procedures using basic and advanced technologies andequipment. • Cognitive skills that will allow the nurse to quickly make decisions based on critical and creative problem-solving skills. The primary work of the nurse involves making accurate assessments, analyzing data, planning and implementing interventions, and evaluating outcomes. The steps of the nursing process are graphically represented in the figure below.

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N104: Essentials of Nursing Care – Health Safety Study Guide

The nursing process:

Assessment

Evaluation

Diagnosis/Analysis

Implementation & Intervention

Planning

1.1 Assessment The nursing process begins with the assessment of the patient. In the assessment phase, the nurse collects, organizes, validates, and documents information about the patient. This part of the nursing process is critical because the information obtained in this stage forms the foundation for the subsequent stages. Purpose of the Assessment The purpose of each assessment of the patient is to: • Collect and organize data about the patient’s physical and psychosocial health in order to identify potential and actual healthproblems • Assess the patient’s functional health and ability to care forhimself • Identify any dysfunctions in the patient’s activities of daily living (ADL) that may impair or impede optimal health • Provide the patient with an opportunity to discuss health concerns and goals withthe nurse Types of Assessments Assessment is not a one-time event. Some sort of assessment is done every time the nurse has contact with the patient or family. There are three types of assessments that the nurse completes: • The comprehensive assessment is the full baseline assessment by the nurse typically done at the time of the initial contact with the patient. This assessment includes a complete health history and current needs assessment that will allow the patient and healthcare team to create measureable goals for the patient.

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N104: Essentials of Nursing Care – Health Safety Study Guide A focused assessment is one that is limited, and focuses on a particular healthcareconcern or risk that has been identified. This will typically be a more in-depth look at just one system or one patient need. • The ongoing assessment is the one used most often by the nurse, since it is the systematic follow-up to issues or problems identified in a comprehensive or focused assessment. Every contact with a patient will involve aspects of the ongoing assessment. The data obtained from these contacts will be used to update the information about the patient and the plan of care with the patient. Types of Assessment Data The nurse collects many types of data during the assessment process: • Data can be classified by the source of the data: o Primary source data is the data that comes directly from the patient through interviews or physical assessment. o Secondary source data is the data that comes from any other source other than thepatient. This might be old medical records, other providers, or friends and family of the patient. • Data can be classified as subjective or objective: o Subjective data are sometimes called symptoms. Symptoms are generally elicited from the patient during the interview process. Symptoms can only be describedby the patient and may or may not be quantifiable. Subjective data will include the patient’s perceptions of his health, sensations he is feeling, thoughts, beliefs, concerns, and attitudes. Subjective data might include things like reported itching, bloated feeling, and worry about health. Symptoms will prompt the astute nurse to look for the objective data to support the subjective reports. o Objective data are called signs. Signs are observable and measurable data that can be obtained through physical assessment or diagnostic testing. Signs can be seen, felt, smelled, or heard by the nurse who is doing the assessment. Signs can be used to validate the symptoms reported by the patient. For example, the nurse may see a rash (the sign) that supports the patient’s report of itching (the symptom). Subjective Data Objective Data Primary Source Data “My back is itching.” Nurse sees a fine rash on the patient’s back. Secondary Source Data “My mother is confused.” “My mother could not remember my father’s name.” Components of the Assessment During the assessment, the nurse must ensure that the patient is comfortable and that the patient’s privacy and modesty are protected. The assessment should be conducted in a quiet, private room. Any of the assessment types may have one or more of these components in the assessment: •

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N104: Essentials of Nursing Care – Health Safety Study Guide • The interview: Effective interviewing involves guiding the patient through the interviewwhile also encouraging the patient to provide as much information as possible. To do this, the nurse uses open and closed-ended questions. A closed-ended question is the one that requires a discrete answer. For example, the nurse asks, “Where are you having pain?” The patient’s answer will include only those body parts where there is pain. Any question that can be answered by a simple “yes” or “no” is classified as closed-ended question. An open-ended question is the one that requires the patient to explain the answer. For example, the nurse asks, “Describe the pain you are having.” This question will require the patient to give additional information about the pain. Both types of questions are legitimate and the astute nurse will use a combination of closed and open-ended questions during the interview. The interview process may also include interviews with the patient’s family or significant others, if the patient has agreed to share information with others. • The physical exam: During the physical exam, the nurse uses all senses to substantiate information collected in the interviews. This examination uses the techniques of inspection (visual examination of the patient), auscultation (listening to sounds produced by the body), palpation (examination using the sense of touch), and percussion (tapping or striking the body surface to produce sounds or vibrations). One of the major functions performed by the nurse is the physical assessment of the patient. In order to do and document the assessment accurately, the nurse must know some of the common terms associated with any assessment. These terms all relate to the standard anatomical position and the locations associated with this position. In the standard anatomical position, the individual has his feet together (or slightly separated) and the arms are rotated outward so that the palms are forward and the thumbs are pointed away from the body. The arms are usually moved slightly out from the body, so that the hands do not touch the sides. Standard anatomical position:

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N104: Essentials of Nursing Care – Health Safety Study Guide As the nurse documents a physical assessment, these terms of location must be used so that anyone reading the documentation will have a very clear understanding of the exact location of the nurse’s findings. o Cranial: Towards the head o Caudal: Towards the feet o Right: On the patient's right side of the body o Left: On the patient's left side of the body o Proximal: Closest to the point where the appendage joins the body o Distal: Furthest from the point where the appendage joins the body o Medial: Toward the middle o Lateral: Toward the side o Anterior: Toward the front of the body o Posterior: Toward the rear of the body o Superior: Above another structure o Inferior: Below another structure o Dorsal: Toward the back of the body o Ventral: Toward the front of the body o Plantar: Pertaining to the sole of the foot o Palmar: Pertaining to the palm of the hand Experienced clinicians will perform each physical assessment in approximately the same order every time. This consistencywill ensure that relevant information is not forgotten. Often, the clinician will perform an assessment from the top of the head to the feet; hence, the term “head to toe assessment.” • The psychosocial assessment: Often overlooked, the psychosocial assessment will provide information about the patient’s psychological health and available support systems. Some of the areas to assess and document include: o Self-esteem: Does the patient make eye contact? Are they well groomed? o Affect: How does the patient’s mood seem to be? Happy? Sad? Flat (that is, there does not seem to be any mood at all)? Euphoric? Appropriate or inappropriate for the situation? o Energy level: Does the patient or family report decreased activity levels? o Support systems: Does the patient have family or friends he can count on? Are they experiencing any crises or stress in the family situation? o Living arrangements: Does the patient live alone, or is there someone in the home who can help with care? Does the patient live in some other living arrangement (assisted living, nursing home, etc.)? o Needs: What does the patient perceives as his or her needs? These may be very different than what the nurse thinks the patient needs. o Goals: What does the patient perceive as his or her goals? Note that these should be documented by the nurse, but may require further development by the team, since the patient’s goals may not be realistic.

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N104: Essentials of Nursing Care – Health Safety Study Guide • The functional assessment: During the functional assessment, the nurse will assess for any difficulty experienced by the patient during activities of daily living (ADL). These activities may include shopping, food preparation, housekeeping, using the telephone, and self-care activities such as bathing, the ability to administer own medications, and the ability to handle finances. • Review all available health records, lab data, or radiology reports. When doing the assessment, the nurse may spend more time in one step than another. For example, in a comprehensive assessment, the nurse will spend a great deal of time doing all the steps of the assessment process. An ongoing assessment might focus more on the physical aspects. Once the nurse has completed the assessment, the process of analysis and diagnosis can begin. 1.2 Analysis and Diagnosis The second phase of the nursing process includes the analysis of the information collected in the assessment phase, the identification of actual and potential health problems, and the formulation of nursing diagnoses. Analysis of the Data Once the data has been collected in the assessment phase, the nurse is ready to begin the analysis of the data. It is helpful to cluster the data into related groups in order to recognize patterns more easily within the data. As the analysis continues, the nurse will begin to see that there may be gaps in the data that will require a focused assessment. For example, notes may suggest the patient being short of breath, but the respiratory rate is 16 and not labored. The astute nursewill go back and do a focused assessment of the respiratory system to validate the data. As the analysis continues, patterns will begin to emerge that will enable the nurse to identify actual and potential problems. Problem Identification Before a plan can be developed, it is critical to identify all of the patient’s problems. Patient problems can be classified as either potential or actual. A potential problem exists when a patient is at risk due to his present illness or some condition identified in the assessment. For example, a patient in traction for a fractured leg is at risk for skin breakdown because of the inactivity associated with being in traction. An actual problem exists when the problem is already present and creating issues for the patient. For example, an elderly patient who has been on bed rest is noted to have skin breakdown (altered skin integrity). Because the condition already exists, it is an actual problem. Any identified problem, whether actual or potential, should be validated with the patient and family (if the patient wants to include them). Nursing Diagnosis Overview Once the list of patient problems is complete, it is time to develop the list of nursing diagnoses. It is critical to understand the difference between medical diagnoses and nursing diagnoses. A medical diagnosis is focused on a disease process and is identified by a physician or advanced practitioner. A nursing diagnosis is focused on human responses to problems. For example, a patient with shortness

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N104: Essentials of Nursing Care – Health Safety Study Guide of breath with activity, difficulty in breathing, and abnormal lung sounds is seen by a physician and a nurse. The medical diagnosis of the physician might be pneumonia. A nursing diagnosis established by the nurse might be “activity intolerance.” The physician will typically only deal with actual problems, while the nurse will focus on both actual and potential problems. In 1973, a conference on nursing diagnosis was held that began to identify the knowledge specific to nursing and a system for classifying that knowledge. Over the next several years, the diagnosis development group, North American Nursing Diagnosis Association (NANDA), worked to develop the NANDA Taxonomy of Nursing Diagnoses. The purposes of this list is to: • Provide all nurses with a standardized language that allows communication amongnurses • Provide a classification system that describes the scientific foundation of nursing practices • Provide a system that can be translated for computer and reimbursement use Other nursing diagnosis classifications exist but the American Nurses Association (ANA) has sanctioned NANDA as the organization to develop the classification system. Developing the Nursing Diagnoses List The process for developing the nursing diagnosis list is: • Identification of the patient problems: In the example of the previous section, the patient with a medical diagnosis of pneumonia was identified as having a problem of “activity intolerance” by the nurse. For potential problems, this part of the nursing diagnosis can be prefaced by “at risk for.” If activity intolerance was only a potential problem, the nurse would document the problem as, “at risk for activity intolerance”. • Identification of the probable cause or etiology of the problem: In the example of the patient with pneumonia, the activity intolerance is caused by or is related to the patient’s shortness of breath. In the context of the nursing diagnosis, the problem and etiology are usually linked by the words “related to” (sometimes abbreviated as “R/T”). In this case, the developing nursing diagnosis would be, “activity intolerance related to imbalance between oxygen supply/demand.” • Identification of any defining characteristics of the problem: The final piece of the nursing diagnosis is the identification of any defining signs or symptoms of the problem. In the patient with pneumonia, the symptommight be the patient’s shortness of breath. In the context of the nursing diagnosis, the problem and etiology are usually linked to the signs and symptoms by the words “as evidenced by” (sometimes abbreviated as “AEB”). In this case, the final nursing diagnosis would be, “activity intolerance related to imbalance between oxygen supply/demand, as evidenced by shortness of breath when walking.” Steps to developing a nursing diagnosis:

AEB Signs & Symptoms

R/T Etiology

Nursing Diagnosis

Problem

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N104: Essentials of Nursing Care – Health Safety Study Guide A patient will typically have several nursing diagnoses. Once developed, the nurse and healthcare team must prioritize the list and plan the care in collaboration with the patient and family. 1.3 Planning As with each phase of the nursing process, the planning phase is always a deliberative process. The nurse develops an initial plan; this initial plan is constantly updated to reflect new data, new problems, or progress toward the completion of a goal. Discharge planning begins at the time of admission and involves the anticipation and planning for the patient’s needs when discharged. The planning phase of the nursing process includes: • Prioritization of nursing diagnoses • Establishing goals or expected outcomes • Identification of nursing interventions that will help a patient achieve the goals • Documentation of the plan of care with measurablecriteria Nursing Diagnosis Prioritization Prioritization of the nursing diagnoses must be based on two considerations: first, what is the most critical or life-threatening problem and second, what problem does the patient consider most critical. A useful mechanism to use for establishing the urgency of a problem is by using Maslow’s hierarchy of needs with the most basic needs requiring the attention first. Using this methodology, problems would be prioritized in the order from the bottom of the hierarchy to the top: • Basic physiological needs (breathing, sleep, excretion, food, etc.) would be classified as the most urgent • Safety needs (security of body, stability, laws, protection, etc.) • Problems related to love and belonging (friendship, family, sexual intimacy, etc.) • Esteem needs (self-esteem, achievement, respect of others, etc.) • Self-actualization needs (creativity, morality, spontaneity, etc.) Maslow's hierarchy of needs:

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N104: Essentials of Nursing Care – Health Safety Study Guide Identification of Goals or Expected Outcomes A goal or expected outcome for the patient is a statement of a measurable change in the behavior or health status, which may be responsive to nursing interventions. The goals or outcomes for the patient will be: • Established through collaboration with the patient, family, and other healthcare team members • Patient-centered, describing what the patient will be able to do or what the patient’s health status will be • Individualized for the patient, taking into account all the data available about thepatient • Based on the nursing diagnoses established with the patient • Observable and measurable • A combination of short term and long-term goals: o Short term goals are those that can be attained within a few hours or days. For example, the patient with “activity intolerance R/T imbalance oxygen supply/demand AEB shortness of breath when walking” might have a short-term goal of, “the patient will use the incentive spirometer five times after every two hours while awake.” o Long term goals are those that will require a longer time for resolution and may extend beyond the current hospitalization. For the patient with activity intolerance, a long-term goal might be, “The patient will increase activity tolerance and be able to walk one mile with no signs of shortness of breath.” The Nursing Outcomes Classification (NOC) is a standardized classification of patients’ outcomes 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 Interventions Classification. Outcomes developed with the patient may be related to health promotion, maintenance, or restoration. Outcomes will be realistic and reflect attainable goals because they are individualized for the patient. Once the expected outcomes are identified, the team will develop the nursing interventions for reaching the goals. Identification of Nursing Interventions Nursing interventions are the actions that are performed by the nurse (or another member of the team) that will help the patient achieve the outcome and the goals. When planning nursing interventions for a patient, there are several standards that must be considered including: • The nurse practice act: Each state has a nurse practice act that defines the scope of practice for a nurse in that state. The nurse practice act defines what a nurse can and cannot legally do. It is critical that the nurse knows the scope of practice in the state where she is licensed. Practicing outside of that scope can lead to revocation of the nurse’s license and can lead to other legal actions.

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N104: Essentials of Nursing Care – Health Safety Study Guide • Policies and procedures at the healthcare organization: Each healthcare organization will typically have a policy and procedure manual (commonly called a P&P manual) that outlines guidelines for how things are done at the specific agency. These manuals are usually very 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.

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Components of a care plan: Component

Activity Example Assessment: Actual or Potential Problems Organize data from the assessment to develop a problem list A patient with recent abdominal surgery is at risk of developing respiratory problems. Nursing Diagnosis Develop the appropriate nursing diagnoses for the identified problems. There may be more than one diagnosis for an identified problem. At risk for ineffective airway clearance, RT impaired ability to cough from incision pain, AEB shortness of breath and shallow respirations. Planning: Goals and Outcomes Define what the expected outcomes for the patient will be. There may be more than one goal for each diagnosis. The patient will demonstrate the ability to deep breath and cough within six hours after surgery. Nursing Interventions Define the interventions that will be used to move the patient towards the expected outcomes. There will typically be more than one intervention for each outcome. Teach the patient to splint the abdominal wound during coughing exercises. Teach the patient how to use the incentive pirometer. Encourage the patient to use the incentive spirometer every two hours while awake. Encourage the patient to cough after each use of the incentive spirometer. 1.4 Implementation/Intervention When the patient’s plan of care has been developed, the implementation phase of the nursing process begins. During this phase the patient, nurse, and the rest of the healthcare team begin the execution of the plan of care. The execution of the plan involves: • Constant assessment and reassessment of the patient: As the plan is implemented, the nurse will use focused and ongoing assessments to determine whether or not the patient needs assistance and whether or not the patient is moving towards the goal and expectedoutcomes. • Implementation of the nursing interventions: When any intervention is done with the patient, the nurse must determine if there was a response and if the response was a positive or negative one. If the intervention elicits a negative response, the intervention will either be changed or deleted from the plan. • Delegation of interventions to other team members: The performance of some nursing interventions may be delegated to other members of the healthcare team. Delegation of tasks does not relieve the nurse of accountability for the care provided. When the nurse makes the decision to have another member of the team perform an intervention, it is critical that the nurse understand:

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N104: Essentials of Nursing Care – Health Safety Study Guide o The specific interventions that each role can perform: Can the person legally do the task? If not, the task cannot be delegated to that person. o The capabilities of the team member: Has the person been trained to do the task? If not, the task should not be delegated until the person has the appropriate training. o The response of the patient to the intervention and the documentation of that response is a nursing responsibility. The person to whom the task is delegated must have a clear understanding of what to watch for during the intervention and what must be reported to the nurse. • Documentation of the activities of care: It is the nurse’s responsibility to record the patient’s status before, during, and after any intervention. This documentation should include information about the patient’s condition before the intervention, what intervention was performed, how the patient responded to the intervention, and the final outcome of the intervention. Any documentation in the patient record should be objective, descriptive, and complete, conveying an accurate picture of the patient’s status and progress toward goals. This documentation provides the following: • A legal record of what was done, by whom, and how the patient responded • A formal means of communication between team members to ensure continuity of care • A record of services that allows for reimbursement of care • A baseline for evaluation of progress toward expected outcomes In addition to the written documentation of progress in the nurses’ notes, the astute nurse will ensure continuity of care by providing succinct and accurate hand-off reports to other team members who assume care for the patient. This hand-off mechanism will vary depending on the practice setting. In some settings, the nurses may have a tape-recorded report fromone shift to the next; in other settings, the hand-off may be a face-to-face report. In any setting, the hand-off should include information that will allow the on-coming nurses to know what interventions have been attempted and how the patient responded to each. During the implementation of the plan, the nurse will also be involved in the evaluation of the plan of care. 1.5 Evaluation The final stage of the nursing process is the evaluation phase. In this phase, the patient, nurse, and healthcare team work together to determine whether the patient goals have been met, partially met, or not met. In order to do this evaluation: • The nurse collects the measurable data to compare with the desired outcomes. The nurse analyzes the data obtained during the implementation phase to determine what variables affected the outcomes. • The nurse, patient, and other healthcare team members collaborate to determine if progress or lack of progress is related to the interventions performed. If goals have not been met, the nurse will try to determine why goals were not fully met. Some of the reasons goals are not met include:

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