Continuous assessment and review of
the plan of care
Since a person’s condition can change dramatically in a
matter of minutes, it is critical to assess the person carefully
before initiating any intervention to make sure the plan of
care is still responsive to the person’s needs and prioritised
to meet the most pressing needs. Before implementing the
planned care it is important to:
•
Ensure that each care intervention is supported by a
sound scientific rationale, as demanded by
evidence-
based practice
•
Ensure that each care intervention is consistent with
professional standards of care and consistent with the
protocols, policies and procedures of the healthcare
facility
•
Ensure that the actions are safe for this particular person
and individualised to their preferences
•
Clarify any questionable orders.
Claire’s condition has now stabilised. The intravenous
therapy has been removed and her blood glucose levels
are consistently between 4.6 and 7 mmol. The dietician
and the diabetes educator have counselled both Claire and
her mother, and follow-up appointments with both have
been arranged. Claire has expressed concerns that she is
having trouble reading and it is impacting on her study.
Part of the implementation of care is the continual assess-
ment and modification of the plan as conditions change,
improve or deteriorate:
1. As Claire’s case has developed, what issues can you
identify that suggest you need to modify the plan of
care?
2. What is new and what has been resolved?
In Chapter 17 you developed a plan of care for Claire
where you identified the assessment data and her health
problems, and developed goals and planned care. It is
now time for you to add to the plan and insert the care
you will implement to address the problems and meet
the goals set.
Refer back to your plan of care and complete the sec-
tions under the headings ‘Care interventions’ and
‘Rationale’.
Organise resources
Successful implementation of the planned care requires a
high degree of organisation and efficiency in today’s hectic
healthcare environments.
Person and visitors
The person needs to be prepared physically and psycho-
logically for any care interventions. Many interventions
are unsuccessful because the person is in too much pain to
cooperate, fails to understand what is being attempted and
therefore does not cooperate, or is simply distracted (may
Unit III Thoughtful practice and the process of care
320
Nurse- and midwife-initiated interventions
involve
carrying out independent care interventions resulting from
the assessment of the person’s needs written on the plan of
care, as well as any other actions they can initiate without
the direction or supervision of another member of the
healthcare team. Nurses and midwives are legally account-
able for their assessments and their care responses.
Policies
are directions formulated by authorities that are
mandatory. These policy statements outline the scope of
practice for practitioners generally and in specific practice
situations.
Protocols
and standing orders expand the scope of prac-
tice in certain clearly defined situations. Protocols are written
plans that detail specific care to be given in certain situations
or to a person with a specific clinical condition. Protocols
define the parameters that the nurse or midwife must practice
within that given situation. For example, many facilities have
protocols relating to wound management practices and dress-
ing products and cardiopulmonary resuscitation.
Procedures
provide a step-by-step guide for an interven-
tion. Some procedures may have policy statements
embedded within them.
Standing orders
are orders that
provide the imprimatur for nurses and midwives to instigate
certain treatments. Some standing orders may apply only to
particular surgeons or doctors, whereas others are com-
monly found in the critical care areas of intensive care and
the emergency departments where a patient’s condition can
change rapidly and where immediate responses are neces-
sary. There may be accreditation programs attached to
standing orders that determine who can enact them. Com-
munity health settings are another area where these requests
are commonly found because the nurse or midwife often
works in isolation and a doctor can be difficult to contact.
Dependent and collaborative nursing
and midwifery action
Doctor-initiated interventions
, or dependent nursing and
midwifery actions, involve carrying out doctor-prescribed
orders. Nurses and midwives are still accountable for
dependent orders they implement and are thus responsible
for the clarification of any questionable order be it of a
clinical, legal or ethical nature.
Collaborative interventions
or interdependent nursing
and midwifery actions are those performed jointly with
other members of the healthcare team. Nurses and midwives
are increasingly involved in collaborative ventures as
members of the healthcare team. Rehabilitative programs
are an example of this type of collaborative care model.
IMPLEMENTING THE PLAN OF CARE
When implementing the plan of care, nurses and midwives
need to be continually working with the person to determine
the need for new or continuing assistance, to promote self-
care and to assist the person to achieve the identified health
goals that are valued by the person.
