Decision for Home Care
• Assessment of home environment
• Learning needs of client and family
• Need for skilled nursing care
• Need for long-term care
Table 9-3 provides an example of standing orders used for client preparation for a barium enema.
Aprotocolis a series of standing orders or procedures that should be followed under certain specific conditions.
They define what interventions are permissible and under what circumstances the nurse is to implement the measures.
Health care agencies or individual prescribing practitioners frequently have standing orders or protocols for client prepa- ration for diagnostic tests and for immediate interventions in life-threatening circumstances. These protocols prevent needless duplication of writing the same orders repeatedly for different clients and often save valuable time in critical sit- uations.
Nursing Interventions Classification
In 1993, the Iowa Intervention Project developed a taxon- omy of nursing interventions that includes both direct and indirect activities directed toward health promotion and ill- ness management. This taxonomy, the Nursing Interventions Classification (NIC), is a standardized language system that describes nursing interventions performed in all practice set- tings. The NIC is a method for linking nursing interventions to diagnoses and client outcomes (Bulechek, Dochterman, &
Butcher, 2007).
The format for each intervention is as follows: label name, definition, a list of activities that a nurse performs to carry out the intervention, and a list of background readings (Bulechek et al., 2007). See Table 9-4 on page 146. The NIC offers standardized language for research on nursing inter- ventions and is a promising tool for determining reimburse- ment for nursing services in a variety of practice settings.
Nursing Intervention Activities
Implementing nursing interventions requires that considera- tion be given to client rights, nursing ethics, and the legal implications associated with providing care. Nursing inter- ventions include:
• Assisting with activities of daily living (ADL)
• Delivering skilled therapeutic interventions
• Monitoring and surveillance of response to care
• Teaching
• Discharge planning
• Supervising and coordinating nursing personnel
Clients have the right to refuse any intervention. How- ever, the nurse must explain the rationale for the intervention and possible consequences associated with refusing treatment.
If the intervention refused was prescribed by another health care professional, that person should be informed of the re- fusal of care. Ethical standards require that clients be afforded privacy and confidentiality. Matters related to a client’s condi- tion and care should be discussed only with individuals directly involved with the client’s care, and any discussion should be held in a location where information cannot be overheard by visitors or bystanders. From a legal standpoint, the nurse must ensure that the authority for prescribing any intervention has been satisfied and that applicable standards of care are maintained during implementation of all nursing interventions. See the accompanying Safety First display.
A
CTIVITIES OFD
AILYL
IVING Clients frequently need assistance with ADL such as bathing, grooming, ambulating, eating, and eliminating. The goal for most clients is to return to self-care or to regain as much autonomy as possible. The nurse’s role is to determine the extent of assistance needed and to provide support for ADL while at the same time fos- tering independence. Ongoing assessment is important for determining the appropriate balance between ensuring safety and promoting independence. For example, maintaining per- sonal grooming is important for purposes of hygiene and comfort as well as for promoting self-esteem. The nurse must always provide privacy when assisting clients with personal hygiene. If these tasks are assigned to other personnel, adequate supervision is imperative to ensure compliance with these principles.T
HERAPEUTICI
NTERVENTIONS Therapeutic nursing inter- ventions are those measures directed toward resolution of aT
ABLE9-3 Example of Standing Orders
DATE
PRESCRIBING PRACTITIONER’S ORDERS
8/1 Standing orders for barium enema
Prior to test:
Clear liquid supper evening prior to test 16 oz citrate of magnesia 6PM
Ducolax tabs iii at 8PM
NPO after midnight
Enemas until clearAMof test Following test:
Milk of magnesia 30 mL PO
Delmar/Cengage Learning
SAFETY FIRST
MAINTAINING STANDARDS OF CARE
If nurses have never performed a specific procedure or feel unsure about their ability to safely perform the skill, they must always secure assistance before implementation.
T
ABLE9-4 Nursing Interventions Classification (NIC) Taxonomy
DOMAIN1DOMAIN2DOMAIN3DOMAIN4DOMAIN5DOMAIN6 LEVEL1: Domains 1.Physiological:Basic Carethatsupports physicalfunctioning 2.Physiological: ComplexCare thatsupports homeostatic regulation 3.BehavioralCare thatsupports psychosocial functioningand facilitateslifestyle changes 4.SafetyCarethat supportsprotection againstharm5.FamilyCarethat supportsthe familyunit
6.HealthSystem Carethatsupports effectiveuseofthe healthcaredelivery system LEVEL2: ClassesAActivityandexercise management:Inter- ventionstoorganize orassistwithphysi- calactivityand energyconservation andexpenditure BEliminationmanage- ment:Interventions toestablishand maintainregular bowelandurinary eliminationpatterns andmanagecompli- cationsdueto alteredpatterns CImmobilitymanage- ment:Interventions
GElectrolyteand acid-basemanage- ment:Interventions toregulateelectro- lyteandacid-base balanceandprevent complications HDrugmanagement: Interventionsto facilitatedesired effectsofpharma- cologicagents INeurologicmanage- ment:Interventions tooptimizeneuro- logicfunctions JInterventionstopro- videcarebefore, OBehaviortherapy: Interventionsto reinforceorpromote desirablebehaviors oralterundesirable behaviors PCognitivetherapy: Interventionstorein- forceorpromote cognitivefunction- ingoralterundesir- ablecognitive functioning QCommunication enhancement:Inter- ventionstofacilitate deliveringand receivingverbaland UCrisismanagement: Interventionstopro- videimmediate short-termhelpin bothpsychological andphysiological crises VRiskmanagement: Interventionstoiniti- aterisk-education activitiesandcon- tinuemonitoring risksovertime
WChildbearingcare: Interventionsto assistinunder- standingandcop- ingwiththe psychologicaland physiological changesduringthe childbearingperiod XLifespancare:Inter- ventionstofacilitate familyunitfunction- ingandpromotethe healthandwelfare offamilymembers throughoutthelife span
YHealthsystemmedi- cation:Interventions tofacilitatetheinter- facebetweenclient/ familyandthehealth caresystem aHealthsystemman- agement:Interven- tionstoprovideand enhancesupport servicesforthe deliveryofcare bInformationmanage- ment:Interventions tofacilitatecommu- nicationsamong healthcarepro- viders (continues)
T
ABLE9-4 (Continued)
DOMAIN1DOMAIN2DOMAIN3DOMAIN4DOMAIN5DOMAIN6 tomanage restrictedbody movementandthe sequelae DNutritionsupport: Interventionsto modifyormaintain nutritionalstatus EPhysicalcomfort promotion:Interven- tionstopromote comfortusingphysi- caltechniques FSelf-carefacilitation: Interventionstopro- videorassistwith routineactivitiesof dailylivingduring,andimmedi- atelyaftersurgery KRespiratoryman- agement:Interven- tionstopromote airwaypatencyand gasexchange LSkin/woundman- agement:Interven- tionstomaintainor restoretissue integrity MThermoregulation: Interventionsto maintainbodytem- peraturewithina normalrange NTissueperfusion management:Inter- ventionstooptimize circulationofblood andfluidstothetis- sue nonverbalmes- sages RCopingassistance: Interventionsto assistanotherto buildonown strengths,toadapt toachangeinfunc- tion,ortoachievea higherlevelof function SClienteduction: Interventionsto facilitatelearning TPsychologicalcom- fortpromotion:Inter- ventionstopromote comfortusingpsy- chologicaltech- niques Bulechek,G.M.,Dochterman,J.M.,&Butcher,H.K.(2007).Nursinginterventionsclassification(NIC)(5thed.).St.Louis,MO:Mosby.ReprintedwithpermissionofElsevier.
current problem and include activities such as administration of medications and treatments, performing skilled procedures, and providing physical and psychological comfort. Written orders must be verified before implementing interventions requiring prescriptive authority. Reassessment of the client is also needed to determine whether the intervention remains appropriate. In addition, a nurse must also understand the ra- tionale, expected effects, and possible complications that could result from any intervention.
M
ONITORING ANDS
URVEILLANCE Observation of the client’s response to treatment is an integral part of the imple- mentation of any intervention. Monitoring and surveillanceof the client’s progress or lack of progress are essential in determining the effectiveness of the plan of care and detect- ing potential complications. Specific interventions require specific monitoring activities; however, typical monitoring activities include observations such as vital signs measure- ment, cardiac monitoring, and recording of intake and out- put. See the Uncovering the Evidence display.
T
EACHING A major intervention in health promotion and illness management is educating clients in order to help them modify their behaviors in response to potential health risks and actual health alterations. As part of this teaching process, nurses must also discuss the rationales for the interventions in the nursing plan of care.Numerous opportunities arise every day for informal teaching related to client care. For example, teaching clients about the medications they are taking and possible side effects should occur routinely as medications are adminis- tered. Similarly, as nurses perform assessment activities, the sharing of observations with the client can be informative in terms of what characteristics are desirable and what observa- tions are sources of concern. This knowledge can be valuable to a client for self-monitoring.
Effective teaching requires insight into the client’s knowledge base and readiness to learn. Realistic teaching goals and learning outcomes should be set on the basis of these factors. It is also desirable to include the family or sig- nificant others in teaching plans. A suitable learning environ- ment should be created that is nonthreatening and allows active participation by the client.
Nurses should be careful to use terminology easily understood by the client. It is important that learning out- comes are validated to be sure that clients can safely and effectively care for themselves after discharge. See Chapter 21 for information about client education.
D
ISCHARGEP
LANNING Preparation for discharge begins at the time of admission to a health care agency. As the aver- age length of stay in acute care settings continues to decrease, early discharge planning becomes imperative. Expected out- comes dictate the type of planning required and the interven- tions necessary to attain the desired outcomes. Interventions directed toward discharge planning include activities such as teaching and consultation with other agencies (e.g., home health, rehabilitation facilities, nursing homes) concerning follow-up care. Teaching related to any changes in diet, medi- cations, or lifestyle must be implemented; any barriers or problems in the home environment must be resolved before discharge from an acute or extended care facility. Some agen- cies employ personnel with the primary responsibility of teaching or discharge planning for groups of clients; however, the nurse who is caring for the individual client is also re- sponsible for ensuring that all appropriate interventions have been implemented before discharge.S
UPERVISION ANDC
OORDINATION OFP
ERSONNEL The management style and type of facility, as well as the needs of the client, determine the scope of interventionsUNCOVERING THE
Eviden ce Eviden ce
TITLE OF STUDY
‘‘Patterns of Nursing Intervention Use across 6 Days of Acute Care Hospitalization for Three Older Patient Pop- ulations’’
AUTHORS
L. L. Shever, M. Titler, J. Dochterman, Q. Fei, and D. M.
Picone
PURPOSE
The purpose of this study was twofold: (1) to identify frequently used nursing interventions and (2) to describe patterns of interventions used for each of the three selected groups of clients.
METHODS
This secondary data analysis study used data from a medical center in which the Nursing Interventions Clas- sification (NIC) was used to electronically document nursing care. Statistics were examined to determine the types, frequencies, and patterns of interventions used in providing care to older care recipients.
FINDINGS
Three interventions (surveillance, IV therapy, and diet staging) were used for all three groups of clients. There were some NIC treatment approaches that were unique to each client population.
IMPLICATIONS
The use of standardized nursing language (i.e., NIC) in electronic medical records enhances the collection and analysis of data. These data serve as guides for nurse managers in making decisions about staffing, resource allocation, and education.
Shever, L. L., Titler, M., Dochterman, J., Fei, Q., & Picone, D. M. (2007).
Patterns of nursing intervention use across 6 days of acute care hospitalization for three older patient populations.International Journal of Nursing Terminologies and Classifications,18(1), 18–29.
associated with supervision and coordination of client care. In a health care facility in which nurses are assigned clients within a total client care management system, responsibilities for supervision might be minimal, whereas facilities that use a variety of ancillary personnel for certain client activities might require a large percentage of time devoted to supervision of care. In home health care, for example, the primary role of the professional nurse might be supervision of personnel who provide assistance with ADL. Although a nurse might dele- gate certain tasks to other personnel, it is still the nurse’s responsibility to ensure that the task was completed according to standards of care and to note the response of the client in order to evaluate progress toward expected outcomes.
Regardless of management style or type of facility, coor- dination of client activities among various health care pro- viders remains the nurse’s responsibility. For example, in acute care settings, the nurse needs to coordinate client activ- ities around the schedule of diagnostic tests or physical therapy.
Scheduling procedures, therapy, treatments, and medications for a number of clients often requires considerable organiza- tional skills, creativity, and resourcefulness.