1. Implementation and Evaluation
Chapter 6
Implementation and Evaluation
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

2. Lesson 6.1 Implementation and Interdisciplinary Care
Theory
Set priorities for providing care to a group of patients.
Identify factors to consider in implementing the plan of care.
Describe the Standard Steps commonly carried out for all nursing procedures.
Clinical Practice
Develop a useful method of organizing work for the day.
Use the Standard Steps for all nursing procedures.
In a global sense, how would you expect achievement of these objectives to be measured? Ultimately, achievement of these objectives will be seen in the development and implementation of effective nursing care plans and in the continual improvement of those plans through an ongoing process of evaluation and revision.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

3. Implementation
Implementing care follows assessment, nursing diagnosis, and planning
The phase of the nursing process in which nursing interventions (or orders) are carried out
Why are reasons or rationales important precursors to carrying out nursing actions? These link the action to the diagnosis and goal of treatment and ensure their value to the patient.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

4. Priority Setting
Change-of-shift report should give clues as to the priority of each action to be implemented
Priorities of care may need to be altered if patient’s condition becomes more acute
When planning time for uninterrupted care, consider the following:
If visitors will be coming
When diagnostic tests are scheduled
What time the physician may come to see the patient
Medication administration schedules
In the clinical setting, interventions are constantly being reprioritized based not only on the patient’s fluctuating situation, but also the unit environment and changing staffing needs.
What is the difference between time-flexible and time-fixed tasks? Time-flexible (can be done any time) tasks are entered onto the worksheet schedule between time-fixed (must be done at a set time) tasks.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

5. Considerations for Care Delivery
Before carrying out specific interventions listed on the plan of care, identify:
Reason for the intervention
Rationale for the intervention
Usual standard of care
Expected outcome
Potential dangers
Some interventions may require an independent nursing action (not requiring a physician’s order)
Check the facility’s policy
How will reviewing these aspects of the planned intervention benefit the patient? By engaging in effective upfront planning and considering the reasons for the action, the standard mechanisms followed in its delivery, the outcome expected from its implementation, and any potential adverse consequences associated with its use, the nurse will be more effective and efficient and the patient will benefit.
Because of the patient’s constantly changing status, interventions written into the nursing care plan may no longer be appropriate to the new situation.
What is the difference in an independent nursing action and a dependent nursing action? The independent action supports the patient’s treatment and attainment of goals, but does not require a physician’s order, as does the dependent action.
What is an interdependent action? Interdependent actions are those that come from collaborative care planning.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

6. Interdisciplinary Care
Some agencies use interdisciplinary care plans, clinical pathways, or care maps to guide care
Interdisciplinary approach to managing patient care
An outgrowth of managed care
Still uses the nursing process
Usually standardized to a medical diagnosis and customized to each patient
Care plan not part of patient’s chart when an interdisciplinary care plan is used; however, nursing process still used
Why is a care plan unnecessary when an interdisciplinary care plan has been established? The interdisciplinary care plan represents a collaborative plan among health care professionals to meet the needs of the patient. It incorporates the elements that would ordinarily be included in the nursing care plan, making a separate plan unnecessary.
What are the benefits of using an interdisciplinary care plan? Standardized care protocols ensure that the experience of one individual does not limit treatment of the patient; collaborative efforts ensure that multiple perspectives are represented in the care plan; greater efficiency can lead to opportunities for more expansive treatment or treatment of more patients; everyone on the health care team is aware of the patient’s progress toward the same general goals.
What are the potential disadvantages of this approach? Unique needs of a patient can sometimes be lost when standardization becomes too routine; involvement of multiple stakeholders can delay decision making, etc.
When this approach is used, who is responsible for monitoring implementation? The RN is usually responsible.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

7. Implementing Care
Employees and students expected to perform at standard of care listed in the procedure manual
For efficient time use, consider which interventions for a patient can be combined
Generally, baths and bedmaking are combined, and the time in the room is used to gather more assessment data or to begin implementing the teaching plan.
Range-of-motion exercises may also be incorporated into the bath routine.
What Standard Steps are always followed when performing a nursing procedure?
Step A: Perform the task according to protocol.
Step B: Check the order, collect the equipment and supplies, and perform hand hygiene.
Step C: Identify and prepare the patient.
Step D: Provide privacy and institute safety precautions; arrange the supplies and equipment.
Step E: Use Standard Precautions and aseptic technique as appropriate.
Step X: Remove gloves and other protective equipment.
Step Y: Restore the unit. Collect the used equipment; dispose of, clean, or store items in the proper places.
Step Z: Record and report the procedure.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

8. Implementation in Long-Term Care
Routine care delegated to nursing assistants
Exercise interventions performed by nursing assistants, physical therapy aides, or restorative aides
Medications may be administered by LVNs/LPNs or nursing assistants with certification in medication administration
Nurse performs any invasive or sterile procedure
Why are tasks delegated in this manner? Delegation controls costs and ensures that the more skilled members of the nursing staff are available for the more involved medical procedures. It also gives staff members an opportunity to develop expertise in certain areas.
When care is delegated, who is ultimately responsible for its delivery? Typically, the licensed  nurse on duty will be responsible for managing the assisting staff and LVNs/LPNs.
Rules for medication administration by an LPN/LVN vary from state to state.  
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

9. Implementation in Home Health Care
In home health, family may be implementing the interventions
Nurse making home visits teaches family to:
Administer medications
Change dressings
Perform range-of-motion exercises
Perform treatments
The nurse performs any invasive procedures or procedures where strict sterility is mandatory
What problems might occur in the home health situation that would not be as likely to occur in a health care facility? The nurse has less control over the delivery of services and documentation in the home health environment. Greater oversight may be required to deliver proper medical care.
What is the most critical role of the nurse in home health care? The education of the patient and family members in the practices that must be followed to maintain the health of the patient
In the home health arena, the LPN/LVN role includes more teaching than in the acute care setting.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

10. Documentation of the Nursing Process
Each intervention must be documented in the patient’s chart
Examples: medications administered, dressings changed, vital signs measured
Procedures not documented are considered not performed
Care is documented on flow sheets daily
It is wise to review the nursing care plan before beginning care to have a clear idea of all of the areas that need written documentation.
Why is documentation so critical? Without proper documentation, medication may be delivered too often, changes in vital signs may not be noted, and other factors that affect patient care may be overlooked.
If the patient’s condition fluctuates greatly from baseline, these changes should be reflected in the documentation.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

11. Question 1 During the implementation of the nursing process:
the planned nursing interventions are carried out.
reassessment of data is used to determine whether the expected outcomes have been achieved.
revision of the nursing care plan is performed.
goals are established for the patient.
Answer: 1
Rationale: During the implementation of the nursing process, the planned nursing interventions are carried out such as administering pain medications for a patient in pain.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

12. Question 2
Before Ms. Bricker, LPN, carries out any interventions such as the administration of a medication, she must know:
the reason for the intervention.
the usual standard of care.
the expected outcome.
any potential danger.
All of the above
Answer: 5
Rationale: Before carrying out any interventions, a nurse must know the reason, standard of care, expected outcome, and any potential dangers.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

13. Question 3
After Ms. Bricker, LPN, has given her patient medication, she returns later to the patient’s room to evaluate the effectiveness of the medication. She knows that in the evaluation phase of the nursing process:
the nursing process has been completed.
she doesn’t need to revise the care plan if needs aren’t met.
if the expected outcomes are considered met, the nurse’s notes must contain data to support this.
there will be no further need for reassessment.
Answer: 3
Rationale: If the expected outcomes are considered met, the nurse’s notes must contain data to support this finding. The evaluation process is a continual process. Ineffective interventions must be revised. If the goals aren’t met, reassessment must be performed to determine what goals would be appropriate.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

14. Lesson 6.2 Evaluation and Quality Improvement
Theory
Determine the steps a nurse uses to evaluate care given.
Discuss the evaluation process and how it correlates with expected outcomes.
Explain the term quality improvement and how it relates to the improvement of health care.  
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

15. Lesson 6.2 Evaluation and Quality Improvement
Clinical Practice
Revise the nursing care plan as needed.
Write an individualized nursing care plan for an assigned patient.
Implement a nursing care plan and evaluate care provided.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

16. Evaluation Based on NFLPN Standard 4c—Evaluation
Once interventions have been implemented, they must be evaluated for effectiveness in reaching the patient’s goals or outcomes
Patient should provide feedback about whether the expected outcome has been met
Evaluation is used to determine if the interventions planned and implemented were effective.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

17. Evaluation in Long-Term Care and Home Health Care
Patient and family should be consulted to find out if the care plan is meeting needs adequately
If expected outcomes are not being met, the interventions are revised
Evaluation is based on data obtained from assessment, analysis of the data, and determination as to whether the specific expected outcomes are being met.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

18. Revision of the Nursing Care Plan
If goals/outcomes are not being reached, the plan must be revised (a continual process)
If goals are reached and the problem is resolved, it is evaluated, signed off in the nurses’ notes as met, and removed from the plan of care
Why is evaluation described as a continual process? Evaluation determines current status of goals/outcomes. Those that have been achieved are removed from the plan. Those with inadequate progress require plan revision, with either the goal or nursing action associated with it changed. Changes in patient status also require changes in goals/outcomes and the means of achieving them. The patient’s health status is not static. Because it is continual, evaluation is a continual process and the nursing care plan is a living document, not a finished product.
Why is documentation important when interventions result in achievement of expected outcomes? Only documented events are considered to have happened. Failure to document is equivalent to stating that the goal has not yet been met.
Documentation must include explicit patient evidence before the met goals are dropped from the plan.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

19. Quality Improvement
Outcome-based quality improvement to determine whether outcomes are effective
Agency-wide evaluation of care delivered by all departments against standards set for each department
Audits at predetermined intervals
Evaluation goal: continuous quality improvement
How can outcome-based quality improvement make nursing care more effective? Periodic, planned evaluation of intervention effectiveness ensures that the overall effectiveness of nursing actions can be determined. This is important because involvement in day-to-day care may make it difficult for a nurse to see more global effects of a treatment. Process improvement should make it easier for the nurse to function effectively.
Who sets the standard for nursing process evaluation? Criteria for these are set by Standards of Clinical Nursing Practice developed by the ANA.
Patient outcomes and organizational outcomes are evaluated. Policy and procedure changes may be indicated by the findings.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

20. Constructing a Nursing Care Plan
RN may construct the initial nursing care plan
If patient admitted to long-term care facility when RN is not available, LPN/LVN may assemble a preliminary nursing care plan that an RN will review and validate as needed the next day
Students, like nurses, must be prepared to care for the patient. A nursing care plan for their assigned patients provides that information.
The nursing process is inherent in every aspect of nursing and is a tool for success as a nurse.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

21. Constructing a Nursing Care Plan (cont’d)
Collect patient data for a database
Analyze the database for potential problems
Choose appropriate nursing diagnoses
Rank the nursing diagnoses in order of priority
Plan the care by defining goals and writing expected outcomes
The RN implements these steps during the development of the nursing plan?  These steps allow for the identification and prioritization of the patient’s problems and the development of the set of expected outcomes of treatment. Without this information, further planning would be impossible.
How is the priority of the nursing diagnoses determined? Priorities are based on the severity and urgency of the problems with which they are associated.
The collection of patient data comes from a variety of sources, including the patient directly.
Physiologic needs are usually, but not always, the patient priorities when rank-ordering the nursing problems.  
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

22. Constructing a Nursing Care Plan (cont’d)
Plan nursing care by choosing appropriate nursing interventions
Implement the nursing interventions
Evaluate outcomes of each nursing intervention; determine whether progress toward achieving expected outcomes has been made
What should happen following an evaluation of the outcomes of a nursing intervention? Appropriate changes should be made to the nursing plan to reflect the changes identified in the patient’s progress toward goals/outcomes.
The nursing interventions should be individualized to the patient situation and written in enough detail to be followed by all other nursing personnel.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

23. Question 4
Debbie, a student nurse, is learning about care plans. She knows all of the following are true regarding care plans except:
the family and patient are invited to the care planning.
the care plan for the home health patient encompasses the needs and concerns of the family as well as the patient.
an LPN is responsible for constructing the care plan.
students are required by most instructors to come to the clinical experience with a nursing care plan in hand for assigned patients.
Answer: 3
Rationale: All of the above are true except 3. An LPN may construct a preliminary nursing care plan; however, an RN will review and modify as needed the next day.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

24. Question 5
Flora, an LPN, is helping her patient understand the side effects of a medication. This is what type of action?
Independent
Dependent
Interdependent
Evaluation
Answer: 1
Rationale: An independent action does not require a physician’s order, but it does require critical thinking and nursing judgment. Nursing judgment is derived from experience and knowledge.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.