Chapter 36 Implementing and Evaluating Care

Aspects of Nursing Implementation After collecting data, identifying nursing diagnoses, developing goals, and writing a nursing care plan, the next step is to implement the care plan. Implementation of a nursing care plan may also be referred to as providing nursing interventions. It involves: Performance of nursing actions Continued data collection Communication with healthcare team Documentation

Nursing Implementation Dependent actions Actions that carry out a physician’s orders regarding medication or treatments Interdependent actions Actions that you perform collaboratively with other care providers Independent actions Actions that do not require a physician’s orders

Nursing Accountability The nurse is responsible for all actions performed, whether they are dependent, interdependent, or independent. This responsibility is also called accountability, an important aspect of the legal requirements of nursing practice.

Skills Used in Implementing Nursing Care Intellectual skills Knowing and understanding essential information before caring for clients; critical thinking Interpersonal skills Believing, behaving, and relating to others Technical skills Changing a sterile dressing or administering an injection, requires safe and competent performance

Communication Solid communication techniques and client encounters that promote the development of a trusting relationship are interpersonal skills that every nurse should possess. Client planning conference or discharge planning conference The nurse gives both verbal and written information to those attending to ensure that the plan of care is not only coordinated with those of other healthcare providers, but also evaluated by them.

Question Which of these is not a step in nursing implementation? a. Putting the nursing care plan into action b. Continuing the collection of data c. Communicating care with the healthcare team d. Identifying strengths and problems e. Documenting care

Answer d. Identifying strengths and problems Nursing implementation includes the following steps: Putting the nursing care plan into action, continuing the collection of data, communicating care with the healthcare team, and documenting care. Strengths and problems are identified in the assessment stage.

Evaluation Evaluation Measures the effectiveness of assessing, diagnosing, planning, and implementing The client is the focus of the evaluation. Steps in the evaluation of nursing care are: Analyzing the client’s responses Identifying factors contributing to success or failure Planning for future care

Evaluation (cont’d) Means to evaluate the effectiveness of nursing care: Client The primary source of evaluation Team conference Helps to plan, evaluate, and design a discharge plan Community health agencies Who are in touch with clients after they leave the facility

Question Which of these are steps of the evaluation stage of the nursing process? a. Modify goals and interventions b. Collect data c. Plan future care d. Document care e. Recognize data clusters

Answer a. Modify goals and interventions c. Plan future care Modifying goals and interventions and planning future care are steps of the evaluation stage of the nursing process. Collecting data and recognizing data clusters are part of the nursing assessment stage. Documenting care is an essential part of the nursing implementation stage.

Discharge Planning Discharge planning Process by which the client is prepared for continued care outside the healthcare facility or for independent living at home Planning for discharge is ongoing throughout the client’s plan of care. The discharge plan is individualized. Healthcare team usually holds a discharge conference with the client to set new goals.

Question Is the following statement true or false? Discharge planning begins on admission of the client into the facility.

Answer True The client and family cannot be expected to remember a large amount of teaching at one time, especially just as the client is leaving the facility. Discharge planning may include written instruction, skills demonstration, and/or verbal teaching. The client, the family, and one or more significant persons may be included in the discharge planning.

Components of Discharge Planning Equipment needed at home Dietary needs: Special diet Medications to be taken at home Resources Emergency response: Danger signs Activity Summary

End of Presentation