14 Implementing and Evaluating

Directory Classroom Response System Questions Lecture Note Presentation

Classroom Response System Questions

Question 1 When initiating the implementation phase of the nursing process, the nurse performs which of the following phases first? Carrying out nursing interventions Determining the need for assistance Reassessing the client Documenting interventions

Question 1 Answer Carrying out nursing interventions Determining the need for assistance Reassessing the client Documenting interventions

Question 1 Rationales Implementing the intervention (or delegating if appropriate) would be the third phase. The second phase would be to determine if assistance is required. Correct. The first phase of implementing is reassessing the client to determine that the activity is still indicated and safe. The last phase would be to document the intervention.

Question 2 Under what circumstances is it considered acceptable practice for the nurse to document a nursing activity before it is carried out? When the activity is routine (e.g., raising the bed rails) When the activity occurs at regular intervals (e.g., turning the client in bed) When the activity is to be carried out immediately (e.g., a stat medication) It is never acceptable

Question 2 Answer When the activity is routine (e.g., raising the bed rails) When the activity occurs at regular intervals (e.g., turning the client in bed) When the activity is to be carried out immediately (e.g., a stat medication) It is never acceptable

Question 2 Rationales Incorrect. Implementation must come before documentation. Incorrect. Implementation comes first. Incorrect. Implementation must come first. Correct. It is never acceptable practice for the nurse to document a nursing activity before it is carried out. Prior charting is inaccurate, misleading, and potentially dangerous because many things can cause an activity to be postponed or cancelled. In a few situations, it may be permissible to chart frequent or routine activities some time at the end of a shift or after a particular interval (e.g., every 4 hours) rather than immediately after the activity.

Question 3 The primary purpose of the evaluating phase of the care planning process is to determine whether: Desired outcomes have been met. Nursing activities were carried out. Nursing activities were effective. Client’s condition has changed.

Question 3 Answer Desired outcomes have been met. Nursing activities were carried out. Nursing activities were effective. Client’s condition has changed.

Question 3 Rationales Correct. The desired outcomes and indicator statements are the parameters by which success is measured. The goal can be met even if nursing activities are not carried out. The goal can be met even if nursing activities are ineffective. Although the desired outcome, by definition, indicates a change in the client’s condition (behavior, knowledge, or attitude), only specific changes (desired outcomes) reflect the success of the care plan.

Question 4 The client has a high-priority nursing diagnosis of Risk for Impaired Skin Integrity related to the need for several weeks of imposed bed rest. The nurse evaluates the client after 1 week and finds the skin integrity is not impaired. When the care plan is reviewed, the nurse should perform which of the following? Delete the diagnosis since the problem has not occurred. Keep the diagnosis since the risk factors are still present. Modify the nursing diagnosis to Impaired Mobility. Demote the nursing diagnosis to a lower priority.

Question 4 Answer Delete the diagnosis since the problem has not occurred. Keep the diagnosis since the risk factors are still present. Modify the nursing diagnosis to Impaired Mobility. Demote the nursing diagnosis to a lower priority.

Question 4 Rationales There is no reason to delete the nursing diagnosis since risk factors are still present. Correct. The risk factors are still present so the diagnosis is still valid. There is no reason to modify the nursing diagnosis since risk factors are still present. There is no reason to demote this to a lower priority because risk factors are still present.

Question 5 What type of action evaluates the length of time clients must wait for a nurse response to a need reported over the intercom on each shift? Structure evaluation Process evaluation Outcome evaluation Audit

Question 5 Answer Structure evaluation Process evaluation Outcome evaluation Audit

Question 5 Rationales A structure evaluation would focus on the setting (e.g., how well equipment functions). Correct. A process evaluation focuses on how care is provided. Outcome evaluations focus on changes in client status (e.g., whether reported satisfaction levels vary with type of person who answers the call light). An audit would be a chart or document review.

Lecture Note Presentation

Learning Outcomes Explain how implementing relates to other phases of the nursing process. Describe three categories of skills used to implement nursing interventions. Discuss the five activities of the implementing phase. Identify guidelines for implementing nursing interventions.

Learning Outcomes (cont'd) Explain how evaluating relates to other phases of the nursing process. Describe five components of the evaluation process. Describe the steps involved in reviewing and modifying the client’s care plan.

Learning Outcomes (cont’d) Describe three components of quality evaluation: structure, process, and outcomes. Differentiate quality improvement from quality assurance.

The Nursing Process - Implementing Action oriented Client centered Outcome directed

Figure 14-1 Implementing. The fourth phase of the nursing process, in which the nurse implements the nursing interventions and documents the care provided. 24

The Nursing Process – Implementing (cont’d) First three phases (Assessing, Diagnosing, Planning) provide basis for nursing actions performed Doing and documenting specific nursing activities and resulting client responses Results examined during evaluating phase

Successful Implementation To implement care successfully, nurses need: Cognitive skills Interpersonal skills Technical skills

Cognitive (Intellectual) Skills Problem solving Decision making Critical thinking Creativity

Interpersonal Skills Verbal and nonverbal Effectiveness depends largely on ability to communicate Therapeutic communication necessary for caring, comforting, advocating, referring, counseling, and supporting

Interpersonal Skills (cont’d) Includes conveying knowledge, attitudes, feelings, interest Appreciation of the client’s cultural values and lifestyle

Technical Skills Purposeful “hands-on” skills Often called tasks, procedures, or psychomotor skills Psychomotor - physical actions that are controlled by the mind, not by reflexes Require knowledge and often require manual dexterity

Five Activities of the Implementing Phase Reassessing the client Determining nurse’s need for assistance Implementing nursing interventions Supervising delegated care Documenting nursing activities

Reassessing the Client Reassess to make sure the intervention is still needed Client’s condition may have changed

Determining the Nurse’s Need for Assistance Inability to implement the nursing activity safely Assistance will reduce stress on the client Nurse lacks knowledge or skills to implement a particular nursing activity

Implementing Nursing Interventions Base actions on scientific knowledge Clearly understand interventions Adapt activities to individual client Implement safe care Provide teaching, support, and comfort

Implementing Nursing Interventions (cont'd) Be holistic Respect the dignity of the client and enhance self-esteem Encourage active client participation

Supervising Delegated Care Nurse still responsible for client’s overall care Must validate and respond to any adverse findings or client responses

Documenting Nursing Activities Record nursing interventions and client responses Do not record in advance!

Evaluating Judgement and appraisal Planned, ongoing, purposeful activity Determines client’s progress, effectiveness of care plan Continuous process Demonstrates nursing responsibility and accountability for their actions

Figure 14-3 Evaluating. The final phase of the nursing process, in which the nurse determines the client’s progress toward goal achievement and the effectiveness of the nursing care plan. The plan may be continued, modified, or terminated. 39

Relationship of Evaluating to Other Nursing Process Phases Depends on effectiveness of preceding steps Assessment data must be accurate and complete Desired outcome must be stated concretely in behavioral terms to be useful for evaluating

Relationship of Evaluating to Other Nursing Process Phases (cont'd) Without implementation/interventions, there would be nothing to evaluate Evaluating and assessing overlap

Figure 14-4 Upon assessment of respiratory excursion, Nurse Medina detects failure of the client to achieve maximum ventilation. She and Amanda reevaluate the care plan and modify it to increase coughing and deep-breathing exercises to q2h.

Components of the Evaluation Process Collect data related to the desired outcomes (NOC indicators) Compare the data with outcomes Relate nursing activities to outcomes Draw conclusions about problem status Continue, modify, or terminate the nursing care plan

Continuing, Modifying, or Terminating the Care Plan Critique each phase of the nursing process Assessment Incomplete or inaccurate databases influence all subsequent steps Diagnosis If incomplete – add new diagnosis statements If complete - analyze whether nursing diagnoses relevant

Continuing, Modifying or Terminating the Care Plan (cont'd) Planning If inaccurate - goals/outcomes need revision If accurate - goals/outcomes realistic and obtainable Have priorities changed? Does client still agree with priorities? Relate to goal achievement Investigate whether best nursing interventions were selected

Continuing, Modifying, or Terminating the Care Plan (cont'd) Implementing After modifications, begin nursing process again

Quality Assurance Ongoing, systematic process Evaluates and promotes excellence in provision of health care May evaluate level of care provided May evaluate performance of a nurse or agency or country

Quality Assurance (cont'd) Three components: Structure evaluation - focuses on setting Process evaluation- focuses on care given Outcome evaluation - focuses on demonstrable changes in client’s health status as result of nursing care

Quality Improvement Joint Commission Mission “To continuously improve the safety and quality of care provided to the public the provision of health care accreditation and related services that support performance improvement in health care organizations.”

Quality Improvement (cont'd) Great emphasis on sentinel event Unexpected occurrence involving death or serious physical or psychological injury or the risk thereof Focuses on process Uses a systematic approach to improve quality of care Often focuses on identifying and correcting a system’s problems

Quality Improvement (cont'd) Also known as: Continuous quality improvement (CQI) Total quality management (TQM) Performance improvement (PI) Persistent quality improvement (PQI)

Quality Improvement (cont'd) National Quality Forum 12 nursing-sensitive care measures to evaluate quality of nursing care Serious reportable events (SREs) or “never events” Facility may not be paid for care if SRE has occurred National Database of Nursing Quality Indicators (NDNQI) - ANA database

Nursing-Sensitive Outcomes Consistently gather data to evaluate quality of nursing care Audit Retrospective audit Concurrent audit