NURSE-3101 Lecture Notes - Lecture 8: Crash Cart, Physical Therapy, Medical Record

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29 Sep 2016
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Chapters 14 and 15 Implementing and Evaluating
Nursing actions planned in the previous step are carried out.
oAssess before performing nursing actions
oRe-assess to determine patient response after performing nursing actions
oRevise your approach as indicated.
If you don’t feel competent to do something, get help!
oThat’s what your instructor is there for!
Direct vs. Indirect Nursing Care
Direct care intervention
oTreatment performed thru interaction with patient.
“The laying on of soapy hands” plus teaching and counseling.
Indirect care intervention
oTreatment performed away from patient but on behalf of patient.
E.g., calling a doctor or documentation.
Direct Care: Activities of Daily Living (ADLs)
Activities usually performed in a normal day:
Everything you do for yourself every day!
Instrumental Activities of Daily Living
Can patient perform these activities at home?
oShopping for food, cooking, cleaning.
oTaking medications.
oWriting checks; handling money matters.
oProvide for personal safety; call 911 if needed; turn off the stove; not let a
stranger in the door; leave the house in case of fire.
Think about these as part of discharge planning.
Other Direct Care Activities
Physical care.
Lifesaving measures.
Controlling for adverse reactions.
Preventive measures.
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Indirect Care
Documentation in the medical record.
Communicating with other members of health care team.
Supervision of other staff
oIncluding making assignments, delegation, direct supervision, follow-up, and
Collecting, labeling, and transporting specimens.
Organizing Resources
oExplain what you’re going to do
Give pain medication
Ask visitors to step out.
oAnticipate what you need and get it.
oThink safety and privacy.
oPull drapes, close door.
oGet help if you need it for lifting/turning and procedures.
What might go wrong?
oDo you need oxygen or suction equipment?
oWhere is the crash cart?
How Should You Organize Your Care?
Know about your patient based on your care plan.
Get report from your instructor or a staff nurse.
Introduce yourself.
o“I’m Gary, I’ll be your nurse today.”
Get vital signs, give a bath, get patient up, help patient eat.
Dressing changes, other interventions.
Medication administration in a timely manner.
Is there a diagnostic test? Surgery? Physical therapy?
Are there any special safety needs? Teaching needs?
Delegation and Nursing Students
oTransfer of responsibility for the performance of an activity to another person
while retaining accountability for the outcome.
If you are asked by a staff nurse to do something you are not trained to do, get your
Never attempt to perform interventions beyond your capacity without the supervision of
your instructor even if instructed to do so by a staff nurse.
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If you work as a patient care technician, follow your job description; do only what is
allowed in your job.
Nurse and patient together measure how well patient has achieved outcomes specified in
the plan of care.
oDiscontinue plan of care when each expected outcome is achieved.
oModify plan of care if there are difficulties achieving the outcomes.
oContinue plan of care if more time needed.
Aim of nursing evaluation
oQuality nursing care that aids patient outcome achievement.
Modifying the plan of care
Delete or modify the nursing diagnosis.
If goal achieved, this is noted on the care plan.
Make the outcome statement more realistic.
Adjust time criteria in outcome statement.
Change nursing interventions.
Computerized care plans usually updated at a specified interval.
Quality and Safety Education in Nursing (QSEN)
Project to meet challenge of preparing future nurses who will have knowledge, skills, and
attitudes necessary to continuously improve quality and safety of health care systems
within which they work.
oSpeak knowledge, skills, and attitudes in QSEN
QSEN competencies help us evaluate the care we give.
Quality, Safe Care Includes:
oThe patient is a full partner in care.
oCare respects the patient’s preferences, values, and needs.
oFunctioning effectively within nursing and within inter-professional teams.
oFollow communication practices that minimize risk associated with handoff and
care transition.
oIntegrate best current evidence with clinical expertise and patient/family
oA culture of safety and minimizing risk of harm to patients through system
effectiveness and individual performance.
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