M10-11

• Nursing intervention


  Any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes
• Nursing interventions


  • Ideally they are evidence based, providing the most current and effective approaches for delivering patient-centered care
• Direct care interventions


  Treatments performed through interactions with patients
• Indirect care interventions


  Treatments performed away from a patient but on behalf of the patient or group of patients, documentation, and interdisciplinary collaboration
• Standardized nursing interventions


  • Clinical practice guidelines and protocols
  • Standing orders
  • Nursing Interventions Classification (NIC) interventions
  • American Nurses Association (ANA) standards
  • Quality and Safety Education for Nurses (QSEN) skill competencies
• Clinical practice guidelines and protocols


  A 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


  Preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problem
• Nursing Interventions Classification (NIC) interventions


  Differentiates nursing practice from that of other health care disciplines by offering a language that nurses
• Clinical judgment


  Includes making appropriate conclusions about interventions to address a patient's response to health conditions or a life process
• Clinical judgment


  • Requires nurse to use or modify standard approaches, sometimes improvise new ones
• Tips for making decisions during implementation


  1. Review the set of all possible nursing interventions for a patient's problem

  2. Review all possible consequences associated with each possible nursing action

  3. Determine the probability of all possible consequences

  4. Judge the value of the consequence to the patient
• Nursing documentation


  The process and art of completing the record of the care provided to a patient which is done in writing or encoded in a computer by the nurse
• Purposes of nursing documentation

  • Communication
  • Legal evidence of care
  • Education
  • Financial billing
  • Evaluation of quality of care rendered
  • Research and statistical information
• Guidelines for recording


  • Accurate and concise
  • Specific
  • Correct spelling
  • Precise
  • Error
  • Sequence
  • Appropriateness
  • Completeness
  • Timing
  • Confidentiality/restricted access
  • Use of ink (permanence)
  • Signature
  • Brevity
  • Legal awareness
• Methods of documentation


  • Narrative Charting
  • Source Oriented Charting
  • Problem Oriented Charting (POMR)
  • SOAP/SAOPIE/SOPIER
  • PIE Charting
  • Focus Charting (DAR)
  • Charting by Exception (CBE)
  • FACT Charting
  • Point of Care Charting/Computerized Charting

  
• Narrative charting


  A chronological account of the client's status, interventions, treatments and client's response to treatment
• SOAP/SAOPIE/SOPIER


  1. subjective data, O- objective data, A- assessment, P- plan, I- implementation, E- evaluation, R- revision
• Problem-Oriented Charting (POMR)


  Focuses on the client's problem and employs a structured, logical format called SOAP charting
• PIE Charting


  Problem, Intervention, Evaluation
• Focus Charting (DAR)


  A documentation method that uses a column format to chart data, action, and response

  
• FACT Charting


  A computer ready FACT system that incorporates many Charting by Exception principles
• Point of Care Charting/Computerized Charting

  Charting done at the bedside or point of care using a computer
• Health care provided in a safe manner and a safe community environment is essential for a patient's survival and well-being
• Safe environment


  • Reduces the risk for illness and injury and helps to contain the cost of healthcare by preventing extended lengths of treatment and/or hospitalization, improving or maintaining a patient's functional status, and increasing a patient's sense of well being
• Physical hazards in the environment

  • Motor vehicle accidents
  • Poison
  • Falls
  • Fire
  • Disasters
• Factors influencing patient safety

  • Patient's developmental level
  • Mobility, sensory, and cognitive status
  • Lifestyle choices
  • Knowledge of common safety precautions
• Risks at developmental stages

  • Infant, toddler, and preschooler
  • School-age child
  • Adolescent
  • Adult
  • Older adult
• Individual risk factors


  • Lifestyle
  • Impaired mobility
  • Sensory or communication impairment
  • Lack of safety awareness
• Risks in the health care agency

  • Medical errors
  • Environmental risks
  • Falls
  • Patient-inherent accidents
  • Procedure-related accidents
  • Equipment-related accidents
• Critical thinking


  • Successful critical thinking requires a synthesis of knowledge, experience, critical thinking attitudes, and intellectual and professional standards
• Nursing diagnosis


  Nursing diagnoses for patients with safety risk
• Nursing diagnoses for patients with safety risk

  • Risk for falls
  • Impaired home maintenance
  • Risk for injury
  • Deficient knowledge
  • Risk for poisoning
  • Risk for suffocation
  • Risk for trauma
• Planning: Goals and outcomes

  1. Prevent and minimize safety threats

  2. Are measurable and realistic

  3. May include active patient participation
• Implementation: Acute and restorative care

  1. Fall prevention

  2. Restraints

  3. Side rails

  4. Acute care safety
• The incidence of patients developing infection as the direct result of contact during health care is increasing
• Nurses are essential in infection prevention and control
• Patients in all health care settings are at risk for acquiring infections because of lower resistance to pathogens; increased exposure to pathogens, some of which may be resistant to most antibiotics; and invasive procedures
• In all health care settings, health care providers, as well as patients and their families, need to recognize sources of infection and be able to apply protective measures
• Patient teaching must include basic information about infection, the various modes of transmission, and appropriate methods of prevention like hand hygiene and covering their cough
• Infection


  The invasion of a susceptible host by pathogens or microorganisms; results in disease