Unit 2 – Nursing Interventions

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Nursing _____ and _____ are the actions that a nurse performs to achieve client goals.
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interventions, activities
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The nurse should choose specific interventions that focus on eliminating or reducing the _____ of the nursing diagnosis.
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etiology
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When it is not possible to change the etiologic factors, the nurse chooses interventions to treat the ____ and _____.
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signs, symptoms
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Interventions for risk nursing diagnoses should focus on measures to _____ the client’s risk factors.
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reduce
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Nursing interventions are identified and written during the ____ step of the nursing process; however they are actually performed during the _____ step.
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planning, implementing
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Nursing interventions include both ____ and ____ care, as well as nurse-initiated, physician initiated, and other provider-initiated treatments.
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direct, indirect,
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____ care is an intervention performed through interaction WITH the client. _____ care is an intervention performed AWAY FROM but on behalf of the client, such as interdisciplinary collaboration or management of the care environment.
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Direct, Indirect
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Independent interventions
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* Are those activities that nurses are licensed to initiate on the basis of their knowledge and skills. * include: -physical care -teaching -ongoing assessment -counseling -emotional support & comfort -environmental management -making referrals to other health care professionals
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In performing an autonomous activity, the nurse determines that the client requires certain nursing _____, either carries these out or delegates them to other nursing personnel, and is ____ for the decision and the actions.
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interventions, accountable
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Dependent interventions
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Are activities carried out under the physician’s orders or supervision, or according to specified routines.
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Dependent interventions
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Physicians’ orders commonly direct the nurse to provide medications, intravenous therapy, diagnostic tests, treatments, diet, and activity. The nurse is responsible for ASSESSING the need for, EXPLAINING, and ADMINISTERING the medical orders. Nursing interventions may be written to individualize the medical order based on the clients status.
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Collaborative interventions
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Actions the nurse carries out in collaboration with other health care team members, such as physical therapists, social workers, dietitians, and physicians.
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Example of collaborative interventions
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The physician orders physical therapy to teach the client crutch-walking. The nurse would be responsible for informing the physical therapy department and for coordinating the client’s care to include the physical therapy sessions. When the client returned to the nursing unit, the nurse would assist with crutch-walking and collaborate with the physical therapist to evaluate the client’s progress.
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choosing nursing interventions
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* consider the consequences of the alternatives *The intervention must be SAFE & appropriate for the client’s age, health, and condition. *The intervention must be ACHIEVABLE with the resources available. *The intervention must be CONGRUENT with the client’s values, beliefs, and culture. *The intervention must be CONGRUENT with other therapies *The intervention must be based on nursing knowledge and experience or knowledge from relevant sciences *The intervention must be within established standards of care as determined by state laws, professional associations (ANA), and the policies of the institution.
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Depending on the type of client problem, the nurse writes interventions for _____, _____, ______, and health _____.
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observation, prevention, treatment, promotion
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observations
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*Include assessments made to determine whether a complication is developing, as well as observation of the client’s responses to nursing and other therapies. *for both actual problems and risk for *ex: observe for redness over sacrum q2h, record intake and output qh
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prevention
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*Interventions prescribe the care needed to avoid complications or reduce risk factors. *mainly needed for potential nursing diagnoses and collaborative problems *ex: turn, cough, and deep breath q2h (to prevent respiratory complications)
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treatments
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*Include teaching, referrals, physical care, and other care needed for an actual nursing diagnosis. *some interventions may accomplish either prevention or treatment functions, depending on the status of the problem. ex: “turn, cough, deep breath q2h” can be intended to treat (existing respiratory problems) or prevent (respiratory complications)
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health promotion
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*Health promotion interventions are appropriate when the client has no health problems or when the nurse makes a wellness nursing diagnosis. *these interventions focus on helping the client identify areas for improvement that will lead to a higher level of wellness and actualize the client’s overall health potential. *ex: discuss the importance of daily exercise
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Delegating is an activity that occurs during the _____ phase of the nursing process. While making the client’s care plan the nurse must also determine who should actually perform the activity.
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planning
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The nurse has two responsibilities in delegating and assigning
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1. appropriate delegation of duties (that is giving people duties within their scope of practice) 2.adequate supervision of personnel to whom work is delegated or assigned.
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Nursing Interventions Classification (NIC)
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-a taxonomy of nursing interventions -updated every 4 years -consists of 3 levels 1.domains 2.classes 3.interventions
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NIC Domains
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1. physiological: basic care the supports physical functioning 2. physiological: complex care that supports homeostatic regulation 3. behavioral care the supports psychosocial functioning and facilitates lifestyle changes 4. safety care that supports protection against harm 5. family care that supports the family unit 6. health system care that supports effective use of the health care delivery system 7. community care that supports the health of the community

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