Implementing Nursing Care

by Samantha Rhea, MSN, RN

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    00:01 Welcome to the implementation phase of the ADPIE process.

    00:05 So, if you recall, we have five-steps to that nursing process.

    00:10 So the I piece of the pie is our implementation phase.

    00:13 I like to call this the action phase, because this is where, as nurses, we get to carry out the functions to help improve our patient condition.

    00:22 So when we're talking about a nursing intervention, just know that this is any treatment based on our clinical judgment and our knowledge base, this is going to help enhance the outcomes of our patient.

    00:33 And this could be for a patient specifically, it could be for a family, or a group, for example.

    00:40 Now, when we're talking about implementation, there's some critical thinking that we need to do.

    00:45 We've got to think about the patient's medical condition, possible outcomes that can occur and expected response.

    00:52 And all of these pieces go into our implementation plan for our patient.

    00:58 So when we're talking about an implementation plan, we have certain nursing interventions that we can choose from.

    01:04 Don't worry about this, guys, you don't have to come up with these on our own.

    01:08 Here are some guidelines for selection of interventions.

    01:12 So, one of the first and foremost is clinical practice guidelines or protocols.

    01:17 So these are particularly from an evidence based practice that shows this type of intervention is best for this specific condition of a patient.

    01:26 Here's a great example of that.

    01:28 Let's say a patient comes into the ER with a stroke, for example.

    01:32 We have specific protocols in how we treat that stroke patient.

    01:37 And we can follow that same order set.

    01:39 So those guidelines and those interventions have been proven to be effective in that particular patient like for stroke.

    01:47 Next, we have standing orders.

    01:49 Guys, nurses love this.

    01:50 This helps us reduce our time in calling the physician many times throughout our shift.

    01:56 So when we talk about a standing order, this is something that's on the patient's orders that we may or we may not use this, Here's a great example.

    02:05 Here's an example of a standing order that you may see really commonly in your practice.

    02:10 Maintain oxygen saturation above 94%.

    02:14 So as a nurse, if we assess our patient and see that the saturation drops below this, then we can intervene, do that event, because we have a standing order.

    02:26 Because with a standing order, the physician has already placed this to where we can follow this and we are not practicing out of our scope of practice.

    02:36 Next, we have interventions.

    02:37 And of course, we know lots about these.

    02:39 These interventions are outlined by NANDA, but these are more nurse driven.

    02:44 So for example, a patient will ambulate three times a day.

    02:47 We don't need an order for this.

    02:49 This is something that's nurse initiated.

    02:53 And lastly, when we're talking about interventions.

    02:55 We've got to think of what we call the ANA, American Nurses Association.

    03:00 They provide standards of nursing practice.

    03:04 It outlines what's ethical and the minimum amount of care that the patient has the right to receive from their nurse.

    03:10 So again, when you're looking at interventions, many times we're going to have best practice and protocols for you to follow depending on the diagnosis, standing orders, nurse initiated interventions, and also ethical standards that we have to go by.

    03:28 Now, when we're talking about implementation.

    03:30 Of course, we always need to go back to assess and reassess the patient and their needs.

    03:36 Now, due to the reassessment piece, and we're about to intervene, we may need to revise the plan of care to what's accurate and appropriate at that time.

    03:45 If we revise this care appropriately, we can organize our care, and then limit the risk of complications when we perform our interventions for our patients.

    03:55 So, of course, when we're talking about implementation, the nurses has the big piece of this, right? because we're going to be the one that carries out those interventions.

    04:03 So as a nurse, we have skills that are key for implementation.

    04:08 One of those being cognitive skills.

    04:10 We have to apply our critical thinking.

    04:13 So this is important because every intervention is not appropriate for every patient.

    04:20 Even if they have the same issue going on.

    04:23 Okay, let me take a minute and repeat that.

    04:26 So, this may seem a little confusing, but every intervention isn't appropriate for the same problem.

    04:32 So we as a nurse have to use our critical thinking skills and decide is this appropriate for a patient? And also, when we're carrying out interventions, there's some interpersonal skills that must be established.

    04:45 We've got to develop trust with our patients, we've got to communicate effectively, because if we don't, the patient's compliance for treatment may not be so good if we don't communicate with our patient and have a good working relationship.

    04:59 And lastly, we have psychomotor skills that we have to perform.

    05:03 So we've got to integrate that cognitive and motor activity, because many of the treatments that we do take hands on nursing skills when we're talking about nursing interventions.

    05:14 So we're talking about implementation.

    05:16 This can come in a number of ways.

    05:19 So this can be direct care, or indirect care.

    05:23 Now, what I mean by this is when we're providing direct care, or direct nursing interventions.

    05:28 These are treatments that are performed through interactions with our patients.

    05:32 So directly with the patient.

    05:34 And sometimes our interventions can even include indirect care.

    05:39 Meaning we're going to perform treatments that are away from the actual patient's bedside, but it's on behalf of the patient.

    05:45 So let me show you what I mean by those.

    05:49 So here's a great example.

    05:50 If you're looking at this long list here on this slide, we've got the direct care piece.

    05:56 So notice, this is the stuff we do hands-on with a patient.

    05:59 Like our assessment, med administration, we're going to help them participate in therapy, etc.

    06:06 Now, when we're talking about indirect care, this is again, more stuff away from more patient.

    06:11 So this can just mean us documenting that care to communicate with other providers, just direct communication with the healthcare team about our patients problem, coordinating care, evaluating, and working with interdisciplinary systems as well.

    06:27 So just know when you're talking about direct and indirect care, all of this is part of the implementation phase for our patients.

    06:36 So when we're talking about implementation of care, sometimes we need to think about teamwork.

    06:41 And we also need to think about delegation when it's appropriate.

    06:45 So I want to orient you to this arrow here.

    06:48 When you're looking at the green piece down here, all the way to the red on the arrow, the green is pretty safe here for delegation, for example.

    06:56 Such as activities of daily living, where maybe the patient needs help bathing, or dressing, or eating, all the way to increase in complexity to those life saving measures.

    07:07 Now, this can include giving invasive drugs.

    07:10 There's a whole list of this that we have to consider in regard to delegation.

    07:15 Is it safe, or is it not? So we have to consider the personnel that we're going to delegate to.

    07:21 Also think about from the red, if you move closer to the green side, these are pieces that were more safely able to delegate.

    07:30 So especially again, those activities of daily living.

    07:34 And you've got to remember, as a nurse, when you delegate aspects of a patient's care, this is a really important point, guys.

    07:42 You are responsible for every task that you delegate to someone because it affects your patient.

    07:49 Here's a great example of that.

    07:50 Let's say, I need a blood pressure taken on a patient.

    07:54 And I delegate my nursing aid.

    07:56 Well, if I get a reading and I medicate off of that, then I have to ensure that that manual blood pressure that was taken was done appropriately and accurately, because I'm going to provide treatment based on that result.

    08:12 Now, when we're talking about implementation, again, we're trying to work with our patient to meet our goals.

    08:17 So if you take a look here on this bridge, we're starting with our treatment plan as a nurse.

    08:23 We've created multiple interventions that may be needed to reach our patient's goal.

    08:27 We also need to remember that there's lots of priorities along the way.

    08:32 And we maybe need to help to anticipate the sequence of those nursing interventions.

    08:37 And also, you've got to remember to invest in the time to make sure the patient understands, you've included them in that plan of care, because this is going to matter when they're carrying out required treatments for that patient.

    08:50 And again, all of these should align with your patients goal.

    About the Lecture

    The lecture Implementing Nursing Care by Samantha Rhea, MSN, RN is from the course Nursing Process – Assessment, Diagnosis, Planning, Interventions, and Evaluation.

    Included Quiz Questions

    1. Any treatment based on clinical judgment and knowledge that the nurse performs to enhance outcomes for the client or in the community
    2. Any treatment based on clinical judgment and knowledge that the nurse performs to enhance outcomes for an individual client only
    3. Any treatment ordered by a physician that the nurse performs to enhance outcomes for the client or in the community
    4. Any treatment specified in the care plan that the nurse performs to enhance outcomes for the client
    1. “I need to reassess my client to make sure my plan of care addresses their current needs.”
    2. “I may need to revise my plan of care to better suit my client’s changing needs.”
    3. “Revising my plan of care would likely increase the risk of complications for my client”
    4. “I don’t need to revise my plan of care, even if my client’s needs have changed.”
    1. Indirect care is performed on behalf of the client but away from the client.
    2. Direct care is performed through interactions with the client.
    3. Indirect care is performed through interactions with the client.
    4. Direct care is performed on behalf of the client but away from the client.
    1. “Standing orders can only be used by physicians, so I will need to find alternative interventions.”
    2. “Nursing Interventions Classification (NIC) interventions are no longer best practice, so I cannot use them."
    3. “I will reference clinical practice guidelines to help me select appropriate interventions.”
    4. “The American Nurses Association (ANA) is a great resource for standards of care.”
    1. Cognitive
    2. Interpersonal
    3. Time management
    4. Psychomotor

    Author of lecture Implementing Nursing Care

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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