1. 14
Implementing
and Evaluating

2. Directory Classroom Response System Questions
Lecture Note Presentation

3. Classroom Response System Questions

4. 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

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

6. 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.

7. 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

8. 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

9. 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.

10. 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.

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

12. 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.

13. 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.

14. 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.

15. 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.

16. 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

17. Question 5 Answer Structure evaluation Process evaluation
Outcome evaluation
Audit

18. 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.

19. Lecture Note Presentation

20. 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.

21. 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.

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

23. The Nursing Process - Implementing
Action oriented
Client centered
Outcome directed

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

25. 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

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

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

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

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

30. 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

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

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

33. 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

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

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

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

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

38. 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

39. Figure 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

40. 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

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

42. Figure 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.

43. 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

44. 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

45. 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

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

47. 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

48. 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

49. 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.”

50. 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

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

52. 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

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