Transcript 05. Implementing Nursing Care, Evaluation

IMPLEMENTING NURSING
CARE, EVALUATION
IMPLEMENTING
Consists of doing and documenting the activities that are the
specific nursing actions needed to carry out the interventions
or nursing orders. The first three nursing process phasesassessing, diagnosing, and planning-provide the basis for the
nursing actions performed during the implementing step. In
turn, the implementing phase, provide the actual nursing
activities and client responses that are examined in the final
phase, the evaluating phase.
While implementing nursing orders, the nurse continues to
reassess the client at every contact, gathering data about
the client’s responses to nursing activities and about
any new problems that may develop. To implement the
care plan successfully, nurses need cognitive,
interpersonal, and technical skills. These skills are
distinct from one another.
The cognitive skills (intellectual skills) include problem
solving, decision making, critical thinking, and
creativity.
Interpersonal skills are all of the activities, verbal and nonverbal,
people use when interacting directly with one another, this
depends on the ability of the nurse to communicate effectively
with others. It is necessary for all nursing activities, caring,
comforting, advocating, referring, counseling, and supporting
others.
Technical skills are hands-on skills such as manipulating
equipments, giving injections and bandaging, moving lifting,
and repositioning clients. These are called procedures, tasks, or
psychomotor skills.
PROCESS OF IMPLEMENTING
• Reassessing the client
• Determining the nurse’s need for
assistance
• Implementing the nursing interventions
• Supervising the delegated care
• Documenting nursing activities
Reassess the Client, to make sure the intervention is still needed.
Even though an order is written on the care plan, the client’s
condition may have changed. The nurse also provides
supportive communication to help alleviate the client’s stress.
Determining the Nurse’s Need for Assistance, for one of the
following reasons:
• The nurse is unable to implement the nursing activities safely
alone
• Assistance would reduce stress on the client
• The nurse lacks the knowledge or skills to implement a
particular nursing activities
Implementing the nursing Interventions, it is important to
explain to the client what interventions will be done, what
sensations to expect, what the client is expected to do, and
what the outcome is. Ensure client privacy, coordinate client
care, and involve scheduling client contacts with other
departments.
WHEN IMPLEMENTING INTERVENTIONS,
NURSES SHOULD FOLLOW THESE
GUIDELINES:
• Base nursing interventions on scientific knowledge, nursing
research, and professional standards of care whenever
possible.
• Clearly understand the order to be implemented and question
any that are not understood.
• Adapt activities to the individual client, a client’s beliefs,
values; age, health status, and environment are factors that can
affect the success of a nursing action.
• Implement safe care
• Provide teaching, support and comfort
to enhance the effectiveness of nursing
care plans.
• Be holistic; view the client as a whole.
• Respect the dignity of the client and
enhance the client’s self- esteem
• Encourage client to participate actively
in implementing the nursing
interventions.
Supervising Delegating Care, if care has been delegated to
other health care personnel, the nurse responsible for all
the client’s care must ensure that the activities have been
implemented according to the care plan
Documenting Nursing Activities, the nurse complete the
implementing phase by recording the interventions and
client responses in the nursing process notes. The nurse
may record routine or recurring activities such as mouth
care in the client record at the end of shift, while some
actions recorded in special worksheets according to agency
policy. Immediate recording helps safeguard the client to
prevent double actions.
EVALUATION
The last phase of the nursing process, follows implementation of
the plan of care, it’s the judgment of the effectiveness of
nursing care to meet client goals based on the client’s
behavioral responses.
The purpose of the evaluation phase of the nursing
process
-measure how well the
patient has achieved
desired outcomes during
and after each intervention
(involves the patient and
nurse)
-identify factors contributing
to the patient's success or
failure
-modify the plan of care and
make changes necessary
based on why the current
plan isn't effective
THE STEPS OF THE EVALUATION PHASE OF
THE NURSING PROCESS
1.
2.
3.
4.
5.
Identifying evaluative criteria
and standards (what are you
looking for when you evaluate
ex: expected patient outcomes)
Collecting data to determine
whether these criteria and
standards are met
Interpreting and summarizing
findings
Documenting your judgement
Terminating, continuing, or
modifying the plan
PROCESS OF EVALUATING CLIENT
RESPONSES
• Collecting data related to the
desired outcomes
• Comparing the data with
outcomes
• Relating nursing activities to
outcomes
• Drawing conclusions about
problem status
• Continuing, modifying, or
terminating the nursing care plan.
When determining whether a goal has been
achieved, the nurse can draw one of the three
possible conclusions:
– The goal was met, that is the client response is the same as
the desired outcomes.
– The goal was partially met, that is either a short term goal
was achieved but the long term was not, or the desired
outcome was only partially attained.
– The goal was not met.
When goals have been partially met or when goals have not been
met, two conclusions may be drawn:
• The care plan may need to be revised, since the problem
is only partially resolved
OR
• The care plan does not need revision, because the client
merely needs more time to achieve the previously
established goals. So the nurse must reassess why the
goals are not being partially achieved.
How can the nursing care plan be modified in
response to evaluation of goals and outcomes?
It can be modified by deleting the existing nursing diagnosis,
being made more realistic, adjusting the time criteria, or
increasing the complexity to facilitate optimal function.
EX: patient may achieve goal too easily and new, more detailed
goal needs to be set
How evaluation relates to the assessment, diagnosis,
planning and implementation phases of the nursing
process
If a goal is unmet, you must re-examine
all steps of the nursing process
(possibly adding to or altering any
of them based on your findings)
NURSING CARE PLANS
STUDENT____________________________________PATIENT INITIALS____________ROOM NUMBER__________DATES________________
ASSESSMENT
NURSING DIAGNOSIS
PLANNING
IMPLEMENTATION
EVALUATION
(supportive data)
FACTUAL DATA
(patient's need)
PROBLEM STATEMENT
(nursing care needed)
NURSING PLAN FOR PROBLEM
(documentation of care)
DOCUMENTATION
(status of goal)
STATUS OF THE GOAL
Supports your problem. This
information has to be
current, or perhaps past
history and NOT “make
believe”. Think of it as
supportive data that proves
you have an actual or
potential problem. It must
have at least 2 pieces of
information to support
problem.
This is the name you give the
problem. Ask yourself,
“What is the problem?”
You can use the NANDA list
of problem statements OR if
none apply, make a problem
statement using one of the
words:
Alteration
Impaired
Deficit
Ineffective
Dysfunction Intolerance
Excess
Ask yourself, “What can I do for
the problem?”
Ask yourself, “Why do I
think this is a problem?”
Think about your pt’s:
1. Medical Diagnoses
S & S from Dx that your
pt is having right now
If no S&S right now, just
list the Dx as support
2. Medication List
Side effects?
3. Abnormal Lab?
These are not to be numbered.
Think about the following:
Observations you make related to
this problem, (include assessment of the pt re: to the body
system re: this problem, diagnostic tests, and reporting of
findings to charge nurse. (Use
your senses).
Refrain from using:
Decreased Cardiac Output*
Disuse Syndrome
Impaired Gas Exchange*
Impaired Physical Mobility
Decreased Mobility (of any kind)
Risk for Infection**
Risk of Ineffective Management of
Therapeutic Regimen*
*These problems must have specific
data, measurements, lab tests, etc. in
order to use these problems.
**There may be some very specific
cases where it may be applicable.
Think, what can an “infection” can
cause? Use that as a problem instead.
Goal: What do you plan to
accomplish? Must be pt centered, AND specific,
measurable, attainable,
realistic, & time-sequenced.
Tasks you can do (things you can
do to prevent, repair, or reduce
the problem). This includes
medication adm., oxygen,
dressing changes, turning,
enema, catheter insertion,
nutrition, fluids, etc.
Teaching of patient & family
(includes not only what the
doctor orders but what you as
the “nurse” will teach the
patient. Also should include
how you will determine the
patient’s understanding of the
teaching.)
Ask, “What will I document?”
Any information that pertains to
the problem.
This is your actual narrative
charting notes just like on your
Assessment Sheet in Level 1 or
charted observations in the nurses
notes in the chart. NOTE: This is
Ask yourself, “Did I
accomplish my goal?”
1. Look at your goal & ask
yourself a question related
to it - whether your Goal
was met completely, met
partially, or not met at all.
Write this down.
2. Answer the question in a
Summarized Evaluation
Statement and relate it to
the Measurable Part of the
Goal. Write this down.
Does the problem or
potential for the problem
still exist? Write this down.
4. Then, state if you will
Continue with your plan either as stated or as
revised or Discontinue Plan.
NOT a restatement of your plan in the
past tense! Also it DOES NOT have to
address each part of the plan. DO
NOT number this section or leave
3.
spaces. Also any conclusions, or
judgments that are improper in
charting are not proper here.
Students have best results in
learning how to word this section
when they do not even look at the
planning section.
Document: Date/Time
1. Observations you made
2. Reporting observations and
changes in condition to
appropriate personnel
3. Care given to the patient
4. Response of the pt to the care
5. Results of your actions,
diagnostic tests, medications
Be very SPECIFIC and very
administered, etc.
THOROUGH. Include details like
6. Teaching specific to patient
how much, frequency (how often),
meds, needs, problems,
etc.
preventative care.
DATE REVISIONS OR
ADDITIONS EVERY DAY!
DATE ENTRY EVERY DAY!
Write this down.
NOTE: You must have
something to back up this
evaluation in your
documentation in the
Implementation column
(Implementation supports or
proves your evaluation
statement).
Examaple:
Goal was partially met. The
patient washed his face but did not
brush his teeth himself. The
problem still exists. Continue
with the plan as revised.
Revised 0705 – 0495