 IMPLEMENTING NURSING CARE

 STANDRAD NURSING INTERVENTION

MODULE 10 

CRITICAL THINGKING IN IMPLEMNETATION
IMPLMENTATION PROCESS
ANTICIPATING AND PREVENTING COMPLICATIONS
NURSING AS A SCIENCE: NURSING PROCESS 
 IMPLEMENTATION SKILLS
 DRECT CARE
 INDIRECT CARE
 ACIRVING PATIENT GOALS
 EVALUATION
 EXAMINE RESULT
 EVALUATIVE MEASIURE
 COMPARE ACHIEVED EFFECT WITH GOALS AND UTCOME
 INTERPRETING AND SUMMARIZING FIDINGS
 RECOGNIZE ERRORS OR UNMET OUTCOMNES
IMPLEMENTING NURSING CARE  CARE PLAN REVISION
 STANDARD FOR EVALUATION
 Implementation is the fourth step of the nursing  DOCUMENTATION AND INFORMATICS
process. It involves delivering nursing interventions  PURPOSES OF THE MEDICAL RECORD
 MISTAKES IN DOCUMENTATION
based on the care plan created from accurate nursing  THE SHIFT TO ELECTRONIC AND DOCUMENTATION
diagnoses, helping the patient achieve the goals and  INTERPROFESSIONAL COMMUNICATION WITHIN THE EDICAL RECORD
outcomes designed to support or improve health.  CONFIDENTIALITY
 PRIVACY, CONFIDENTIALITY AND SECIRITY MECHANISMS
 Nursing interventions are actions performed by  HANDLING AND DISPOSING IF INFORMATION
nurses, based on clinical judgment and evidence, to  STANDARDS
 GUIDELINES FOR UALITY DOCUMENTATION
enhance patient outcomes.  METHODS OF DOCUMENTATION
o Direct care interventions involve direct  METHOD OF REPRTING
 COMMON RECORD KEEPING FORMS
interaction with patients (e.g., administering  ACUITY RATING SYSTEMS
medications, providing physical care).  DOCUMENTATION IN THE HOME HEALTH CARE SETTING
o Indirect care interventions involve actions  DOCUMENTATION IN THE LONG-TERM HEALTH CARE SETTING
 DOCUMENTING COMMUNICATION WITH PROVIDERS ANDUNIUE EVENTS
performed away from the patient but on  INFORMATICS AND INFORMATION MANAGEMENT IN HEALTH CARE
behalf of them (e.g., documentation,  NURSING INFORATICS
 CLINICAL INFORMATION SYSTEM
interdisciplinary collaboration).  NURSING CLINICAL INFORATION SYSTEMS

STANDARD NURSING INTERVENTIONS

 Standardized interventions are actions based on clinical guidelines, protocols, or classification systems like the Nursing
Interventions Classification (NIC).
o Nurse-initiated interventions involve care actions based on nursing knowledge.
o Health provider-initiated interventions are prescribed by healthcare providers (e.g., standing orders).
o Clinical guidelines and protocols help nurses make decisions about the best treatment for specific conditions.

CRITICAL THINKING IN IMPLEMENTATION

 Clinical judgment is essential for making appropriate decisions on interventions.
o Tips for making decisions: Review all nursing interventions, evaluate consequences, and judge the patient’s
priorities.
o Nurses must adjust standard interventions and improvise based on the clinical situation.

IMPLEMENTATION PROCESS
 Reassessing the patient should be continuous and at every interaction to ensure care plans remain relevant.
 Reviewing and revising the care plan involves validating diagnoses and ensuring nursing interventions align with the
patient's needs.

ANTICIPATING AND PREVENTING COMPLICATIONS

 Preventing complications requires identifying risks, evaluating the benefits vs. risks of interventions, and initiating
preventive measures.
 Assistance: Nurses may seek guidance or help from other professionals to prevent complications during implementation.

IMPLEMENTATION SKILLS
 Different types of skills are required for implementation:
o Cognitive skills: Critical thinking to determine the most appropriate care.
o Interpersonal skills: Effective communication and relationship-building with the patient and team.
o Psychomotor skills: Physical actions required for direct care (e.g., administering injections).

DIRECT CARE
 Involves interactions with the patient.
o Activities of daily living (ADLs): Ambulation, eating, dressing, bathing.

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 o Physical care techniques: Safe administration of nursing procedures.
o Lifesaving measures: Actions required to prevent harm (e.g., CPR).
o Counseling and teaching: Providing emotional support and educating the patient on health management.

INDIRECT CARE
 Performed away from the patient but supports their care.
o Managing the environment: Ensuring safety and infection control.
o Documentation: Recording patient information and care actions.
o Collaboration: Working with the interdisciplinary healthcare team.

ACHIEVING PATIENT GOALS

 Nurses focus on implementing care to achieve patient goals, considering priorities, and using multiple interventions as
necessary.
 Patient adherence is essential, requiring collaboration with the patient and family to ensure they are invested in their care
plan.

EVALUATION
 Evaluation is the final step, where the nurse determines if patient outcomes have been achieved.
 Expected outcomes are used to judge the success of care, focusing on patient well-being and not the completion of
interventions.

EXAMINE RESULTS
 Reflection-in-action: Continuously reviewing the patient's response to interventions, considering subjective and objective
data.

EVALUATIVE MEASURES
 Evaluation tools: Nurses use assessment skills, behavioral observations, and self-management metrics to evaluate care
effectiveness.
o Nursing Outcomes Classification (NOC) helps quantify patient outcomes.

COMPARE ACHIEVED EFFECT WITH GOALS AND OUTCOMES

 Comparing data: The nurse compares clinical, behavioral, and self-report data before and after interventions to assess goal
achievement.

INTERPRETING AND SUMMARIZING FINDINGS

 Nurses need to interpret results and compare them with expected outcomes. Early detection of issues is vital for
successful patient care.

RECOGNIZE ERRORS OR UNMET OUTCOMES

 Nurses must engage in self-reflection to identify errors or unmet outcomes.
o Corrective actions are taken based on the findings.

CARE PLAN REVISION

 Care plan adjustments are made based on evaluation:
o Discontinuing care plans when goals are met.
o Modifying care plans by reassessing diagnoses, goals, and interventions.

STANDARDS FOR EVALUATION

 Evaluation involves assessing if nursing care has resolved health problems, prevented potential issues, or maintained
health.
o ANA standards guide evidence-based nursing evaluation.

DOCUMENTATION AND INFORMATICS

 Documentation creates a record of nursing actions, decisions, and patient responses. It ensures continuity, quality of care,
and accountability.
 Electronic Health Records (EHR) improve care quality and decrease healthcare costs.

PURPOSES OF THE MEDICAL RECORD

 Communication: Sharing patient information across the healthcare team.
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  Reimbursement: Justifying healthcare costs for insurance or government programs.
 Research and legal documentation: Recording care for evidence and legal purposes.

MISTAKES IN DOCUMENTATION
 Common errors include failing to record significant information like medications, actions, and changes in conditions, which
can lead to malpractice claims.

THE SHIFT TO ELECTRONIC DOCUMENTATION

 HITECH Act encourages the use of Electronic Health Records (EHRs), improving care quality, reducing costs, and enhancing
communication among healthcare providers.

INTERPROFESSIONAL COMMUNICATION WITHIN THE MEDICAL RECORD

 Effective communication in the record is crucial to prevent care fragmentation, duplication, and delays. Nurses must
ensure the care plan is communicated across the team.

CONFIDENTIALITY
 Nurses are legally and ethically required to maintain patient confidentiality and protect health records from unauthorized
access (HIPAA).

PRIVACY, CONFIDENTIALITY, AND SECURITY MECHANISMS

 Security mechanisms (e.g., encryption, restricted access) protect patient data from unauthorized use or exposure in
electronic systems.

HANDLING AND DISPOSING OF INFORMATION

 Proper handling includes de-identifying patient data and using secure methods for disposing of or transferring information,
such as using privacy filters or shredding documents.

STANDARDS
 Nurses must follow institutional standards and guidelines for documenting care to maintain accreditation and minimize
liability.

GUIDELINES FOR QUALITY DOCUMENTATION

 Factual, accurate, complete, current, and organized documentation is necessary for effective patient care and legal
compliance.

METHODS OF DOCUMENTATION
 Narrative: Traditional method of describing care.
 Problem-Oriented Medical Record (POMR): Focuses on problems and includes database, care plan, and progress notes.
 SOAP: Subjective, Objective, Assessment, Plan.
 SOAPIE: Adds Intervention and Evaluation to SOAP.
 PIE: Problem, Intervention, Evaluation.
 DAR: Data, Action, Response.

METHODS OF REPORTING
 Charting by exception (CBE): Focuses on documenting deviations from normal findings.
 Critical pathways: Multidisciplinary approach incorporating variances and goal tracking.

COMMON RECORD-KEEPING FORMS

 Admission history forms: Guide through the assessment process.
 Flow sheets and graphic records: Track patient trends over time.
 Care summaries: Provide concise patient information for quick review.
 Discharge summaries: Record key information for patient discharge.

ACUITY RATING SYSTEMS

 Acuity ratings determine the required staff levels and hours of care based on patient needs.

DOCUMENTATION IN HOME HEALTH CARE

 Home care nurses document services provided for reimbursement, following Medicare and Medicaid guidelines.

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 DOCUMENTATION IN LONG-TERM HEALTH CARE
 Long-term care documentation supports an interdisciplinary approach and meets governmental standards.

DOCUMENTING COMMUNICATION WITH PROVIDERS AND UNIQUE EVENTS

 Nurses must document telephone and verbal orders, as well as incidents and occurrences, following agency protocols.

INFORMATICS AND INFORMATION MANAGEMENT IN HEALTH CARE

 The TIGER initiative focuses on improving healthcare delivery through technology and informatics.
 Nursing informatics combines nursing practice with information technology to enhance care delivery.

NURSING INFORMATICS
 Utilizes technology to support nursing practices, including patient care, education, administration, and research.

CLINICAL INFORMATION SYSTEMS

 CPOE (Computerized Provider Order Entry) allows providers to enter orders electronically.
 CDSS (Clinical Decision Support Systems) help in making clinical decisions.

NURSING CLINICAL INFORMATION SYSTEMS

 Allows nurses to access real-time patient data at the bedside, share care plans, and check lab results.

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