Nursing process

Implementing and Evaluating

Implementing and Evaluating
 Learning outcomes
After completing this chapter, you will be able to:
1. Explain how implementing relates to other phases of the nursing process.
2. Describe three categories of skills used to implement nursing interventions.
3. Discuss the five activities of the implementing phase.
4. Identify guidelines for implementing nursing interventions.
5. Explain how evaluating relates to other phases of the nursing process.
6. Describe five components of the evaluation process.
7. Describe the steps involved in reviewing and modifying the client’s care
plan.
8. Describe three components of quality evaluation: structure, process, and
outcomes.
9. Differentiate quality improvement from quality assurance.
 implementing
• implementing is the action phase in which the
nurse performs the nursing interventions.
• consists of :
1 - doing .
2 – documenting .
(performs the nursing activities or the interventions
that were developed in the planning step and then
concludes the implementing step by recording nursing
activities and the resulting client responses)
 American Nurses Association
(ANA) Standards
• The fifth standard of the (ANA) Standards of
Practice is implementation.
• First Three apply to all registered nurses:
1. coordination of care.
2. health teaching and health promotion.
3. consultation.
4. prescriptive authority .
5. treatment, applies only to advanced practice
nurses .
 Relationship of Implementing to Other
Nursing Process Phases
• first three nursing process phases provide the basis for the nursing
actions performed during the implementing step.
• implementing phase provides the actual nursing activities
• Using data acquired during assessment, to individualize the care given
in the implementing phase, tailoring the interventions to fit a specific
client rather than applying them routinely to categories of clients
• client responses that are examined in the final phase, (evaluating
phase).
• While implementing nursing care, the nurse continues to reassess the
client at every contact, gathering data about the client’s responses to
the nursing activities and about any new problems that may develop.
 Implementing Skills
cognitive skills (intellectual skills)
• Include problem-solving, decision-making, critical thinking,
clinical reasoning, and creativity. They are crucial to safe,
intelligent nursing care
Interpersonal skills
• all of the activities, verbal and nonverbal, people use when
interacting directly with one another.
• Therapeutic communication techniques to understand the client
and in turn be understood
• work effectively with others as a member of the healthcare
team.
• Include conveying knowledge, attitudes, feelings, interest, and
appreciation of the client’s cultural values and lifestyle.
• necessary for all nursing activities: caring, comforting,
advocating, referring, counseling, and supporting are just a few.
 Implementing Skills
• Technical skills
• physical actions that are controlled by the
mind, not by reflexes.
• skills ,tasks, procedures, or psychomotor
skills.
• Technical skills require knowledge and,
frequently, manual dexterity.
 Process of Implementing

1. Reassessing the client

2. Determining the nurse’s need for assistance
3. Implementing the nursing interventions
4. Supervising the assigned care
5. Documenting nursing activities.
 Process of Implementing (cont’d)

1. Reassessing the client

• reassess the client to make sure the
intervention is still needed before
implementing an intervention.
• New data may indicate a need to change the
priorities of care or the nursing activities.
 Process of Implementing (cont’d)
2. Determining the Nurse’s Need for Assistance
• The nurse may require assistance for one or
more of the following reasons:
a. The nurse is unable to implement the nursing
activity safely or efficiently alone
b. Assistance would reduce stress on the client
c. The nurse lacks the knowledge or skills to
implement a particular nursing activity
 Process of Implementing (cont’d)
3. Implementing the Nursing Interventions

• explain interventions to the client .

• ensure the client’s privacy .
• coordinate client care
 Implementing interventions guidelines:
• Base nursing interventions on evidence-based practice .
(scientific rationale, side effects , complications, of all
interventions).
• Clearly understand the interventions to be implemented
and question any that are not understood.
(knowledge of each intervention, any contraindications and
changes in the client’s condition)
• Adapt activities to the individual client.
(client’s beliefs, values, age, health status, and environment)
• Implement safe care.
(prevent infection, administers the correct medication dosage
by the ordered route).
 Implementing interventions guidelines
• Provide teaching .
(explain the purpose of interventions, what the client will experience,
and how the client can participate).
• Be holistic.
(view the client as a whole and consider the client’s responses in that
context).
• Respect the dignity of the client and enhance the client’s self-
esteem.
(by Providing privacy and encouraging clients to make their own
decisions)
• Encourage clients to actively participate in implementing the nursing
interventions.
(To enhances the client’s sense of independence and control).
 Process of Implementing (cont’d)
4. Supervising Delegated or Assigned Care
• If care has been delegated to other healthcare personnel, the
nurse responsible for the client’s overall care must ensure that
the activities have been implemented according to the care plan
• Other caregivers may be required to communicate their
activities to the nurse by documenting them on the client
record, reporting verbally, or filling out a written form.
• validates and responds to any adverse findings or client
responses.(may involve modifying the nursing care plan).
• delegation involves another individual completing a specific
nursing activity, skill, or procedure that is routinely out of
traditional role.
 Process of Implementing (cont’d)
5. Documenting Nursing Activities
• part of the agency’s permanent record for the client.
• the nurse completes the implementing phase by recording the
interventions and client responses in the nursing progress
notes after carrying out the nursing activities.
• Nursing care must not be recorded in advance because the
nurse may determine on reassessment of the client that the
intervention should not or cannot be implemented.
• record routine or recurring activities in the client record at the
end of a shift.
• In some instances, it is important to record a nursing
intervention immediately after it is implemented (e.g.
administration of medications).
• Nursing activities are communicated verbally as well as in
writing.
Evaluating
 Evaluating
• evaluate is ( judge or appraise).
• fifth phase of the nursing process.
• Evaluating is a planned, ongoing, purposeful activity in which
clients and healthcare professionals determine
(a) the client’s progress toward achievement of goals or outcomes
(b) the effectiveness of the nursing care plan.
• Important because conclusions drawn from the evaluation
determine whether the nursing interventions should be
terminated, continued, or changed.
• continuous.
• done while or immediately after implementing a nursing order
enables the nurse to make on-the-spot modifications in an
intervention.
 Evaluating
• performed at specified intervals
• extent of progress toward achievement of goals or
outcomes and enables the nurse to correct any deficiencies
and modify the care plan as needed.
• continues until the client achieves the health goals or is
discharged from nursing care.

• Evaluation at discharge includes :

1. the status of goal achievement
2. and the client’s self-care abilities with regard to follow-up
care.
 Importance of Evaluating
• nurses demonstrate responsibility and
accountability for their actions
• indicate interest in the results of the nursing
activities.
• demonstrate a desire not to perpetuate
ineffective actions and instead to adopt more
effective ones.
 Relationship of Evaluating to Other Nursing Process
Phases
• Successful evaluation depends on the effectiveness of the
steps that precede it.
• Assessment data must be accurate and complete so that the
nurse can formulate appropriate nursing diagnoses and
desired outcomes.
• The desired outcomes must be stated concretely in behavioral
terms if they are to be useful for evaluating client responses.
• without the implementing phase in which the plan is put into
action, there would be nothing to evaluate.
• collects data for the purpose of comparing it to preselected
goals or outcomes and judging the effectiveness of the
nursing care.
Process of Evaluating Client Responses

• the nurse identifies the desired outcomes

(indicators) that will be used to measure client
goal Achievement Before evaluation.
Desired outcomes purposes:
a. They establish the kind of evaluative data that
need to be collected
b. provide a standard against which the data are
judged.
 components of evaluation phase
• Collecting data related to the desired
outcomes (NOC indicators)
• Comparing the data with outcomes
• Relating nursing activities to outcomes
• Drawing conclusions about problem status
• Continuing, modifying, or terminating the
nursing care plan
 components of evaluation phase
1. Collecting Data :
• Using the clearly stated, precise, and measurable
desired outcomes as a guide.
• the nurse collects data so that conclusions can be
drawn about whether goals have been met.
• necessary to collect both objective and subjective
data.
• Some data may require interpretation
• Data must be recorded concisely and accurately to
facilitate the next part of the evaluating process.
 components of evaluation phase
2. Comparing Data with Desired Outcomes :
• Both the nurse and client play an active role in comparing the client’s actual
responses with the desired outcomes.
• three possible conclusions:
1. The goal was met; that is, the client response is the same as the desired
outcome.
2. The goal was partially met; that is, either a short-term outcome was achieved
but the long-term goal was not,
or the desired goal was incompletely attained.
3. The goal was not met.
• After determining whether or not a goal has been met, the nurse writes an
evaluation statement .
• evaluation statement parts :
1. conclusion (the goal or desired outcome was met, partially met, or not met.
2. supporting data (list of client responses that support the conclusion) .
 components of evaluation phase
3. Relating Nursing Activities to Outcomes:

• Determining whether the nursing activities

had any relation to the outcomes.
• never be assumed that a nursing activity was
the cause of or the only factor in meeting,
partially meeting, or not meeting a goal.
 components of evaluation phase
4. Drawing Conclusions About Problem Status :
• uses the judgments about goal achievement to determine whether
the care plan was effective in resolving, reducing, or preventing
client problems.
When goals have been met , conclusions may be drawn:
• The actual problem stated in the nursing diagnosis has been
resolved, or the potential problem is being prevented and the risk
factors no longer exist (documents that the goals have been met
and discontinues the care for the problem).
• The potential problem stated in the nursing diagnosis is being
prevented, but the risk factors are still present(keeps the problem
on the care plan).
• The actual problem still exists even though some goals are being
met(the nursing interventions must be continued even though this
one goal was met).
 components of evaluation phase
When goals have been partially met or when goals have not
been met, conclusions may be drawn:
• revised care plan, since the problem is only partially resolved.
The revisions may need to occur during the assessing,
diagnosing, or planning phases, as well as during
implementing.
• Or The care plan does not need revision, because the client
merely needs more time to achieve the previously established
goal
• To make this decision, the nurse must assess why the goals
are being only partially achieved, including whether the
evaluation was conducted too soon
 components of evaluation phase

5. Continuing, Modifying, or Terminating the NCP :

• modifies the care plan as indicated after drawing
conclusions about the status of the client’s problems.
• Modifications (drawing a line , marking portions
using a highlighting pen, may also write
“discontinued” (“dc’d”), “goal met,” or “problem
resolved” and the date.
• Determine the effectiveness of the plan as a whole.
• review of the entire care plan and a critique of each
step of the nursing process.