Fundamentals of Nursing and Midwifery 2e

Unit III Thoughtful practice and the process of care

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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

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.