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Chapter 7:Nursing Process: Implementation & Evaluation
Fundamemntals of Nurisng
42
Nursing
10/18/2009

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Cards

Term

 

Nursing Process:

Implementation & Evaluation

Definition
Term

 

Implementation

Definition

You will perform or delegate planned interventions---that is, carry out the care plan.

 

The implementation phase ends when you record the nursing actions on the chart; It evolves into evualtion as you record the resulting client responses.

Term

 

How is Implementation related to other steps of the Nursing Process?


Definition

Nursing Process are interdependent.

 

Implementation overlaps with assessment.

 

Implementation overlaps with diagnosis

 

Implementation overlaps with planning outcomes

 

Implementation overlaps with evaluation

Term

 

 

How should I prepare for Implementation?

Definition

In addition to "doing,delegating, and recording", implementation als involves some preparation.

 

You should do some more planning just before implementing the plan.

Term

 

Check your Knowledge and Abilities

Definition

* You do not have the knowledge or skill needed to implement an order

eg. You may be unfamiliar with a medication

 

* You cannot perform the activinty safely alone.

eg. helping a heavy, weak patient to ambulate.

 

Performing the activity alone would cause undue stress for the patient.

eg. giving back care to a patient with multiple fractures.

Term

 

Establish feedback Points

Definition

Establishing feedback points is a part of organizing your work.

 

You cannot assume you will be able to carry out a nursing order in exactly the way it was written.

 

feedback is not always verbal.

eg. it could change in vital signs,skin color, or lelvel of consciousness.

Term

 

Feedback

 

Definition

(patient reponsnes to activity)

as you perform care.

Term

 

Prepare Supplies and Equipment

Definition

Gather all the supplies and equipment you need before you go to the patients room.

 

Prevents stress to the patient when you leave them alone to go get something you have forgotten

Term

 

Prepare the Patient

Definition

*Check your assumptions

 

*Check the patient readiness

 

*Explain what you will do and what the patient will feel.

 

*provide privacy


Term

 

Implementing the plan:Doing or Delegating

Definition

During implementation you will coordinate and carry out both the nursing orders on the nursing are plan and the medical orders that relater to the patients medical treatment.

Term

 

How can I promote client particiaption and adherences

Definition

* Assessing the clients knowledge.

 

*Assessing the cleints support

 

*Being sensitive to the cleints cultural,spiritual, and other needs and viewpoints.

 

*Realizing abd accepting that some attitude cannot be changed.

Term

 

How can I promote client particiaption and adherences

(cont'd)

Definition

*Determining the client's main concerns.

 

*Helping the client to set realistic goals

Term

 

 

Coordination

Definition

Care includes schedueling treatments and activities with other departments, but it is more than that.

eg. laboratory, physical therapy, radiology department

Term

 

Delegation

Definition

The transfer to another person of the authority to perform a task in a sleelcted situation--the person delegating retains accountability for the outcome of the activity.

Term

 

The five right's of delegation

Definition

* Right Task

 

*Right circumstances

 

*Right person

 

*Right direction/Communication

 

*Right Supervision

 


Term

 

Evaluation: the final step of the nursing process

Definition

Evaluation- the final step of the nursing


process., is a planned. ongoing,systematic


activity in which you will make judgements about:

 

*the clients progress toward desired health outcomes.

*the effectiveness of the nursing care plan.

*the quality of nursing care in the helath care setting

 

Term

 

Why is evaluation essential to full spectrum nursing?


Definition

*The patient is the nurses first prioty.

 

*Evalaution helps nurses to conserver scarce resources.

 

*Professional standards of practice require evaluation.

 

*The Ana code of ethics requires evaluation.

 

*The JCAHO  and professional standards review organizations require evaluation.

Term

 

Why is evaluation essential to full spectrum nursing?

(cont'd)

Definition

* Evaluation helps ensure nursing survival

 

*Evlaution demosntrates caring and responsiblity.

Term

 

How are standards and criteria Used in evalaution?

Definition

Criteria-Are measurable or observable characteristics, properties,attributing, or qualities.

 

Reliable- If it yields consistent results--the same results every time, regardless of who uses it.

 

Valid- It is really measured what it was intended to measure.

Term

 

Types of Evalaution

Definition

Evlaution is categorized according to:


1. what is being evlauted(strucutres, processes, or outcomes)

 

2. Frequency and time of evaluation

Term

 

Structure Evaluation

Definition

Focuses on the setting in which care is provided.

 

It explores the effect of orgnaizational characteristics on the qulatiy of care.

 

Requires standards and data about plocies, procedures, fiscal resources, physical facilites and euqipments.


Term

 

Process evaluation

Definition

Focuses on demonstrable(measurable changes) in the patient's health status that result from the care given.

Term

 

Ongoing evaluation

Definition

While implementing, immediatel;y after an intervention or each patient contact

Term

 

Intermittent Evaluation

Definition

Performed at specified times.

 

It enables you to judge the progress toward goal acheivement and to modify the care plan as needed.

Term

 

Terminal Evaluation

Definition

Describes the cleints health status and prgress toward goals at the time of discharge.

Term

 

How is Evlaution related to other steps of the nursing process?

Definition

Teh patient outcomes stated in the planning outcomes stage must be concrete, observable and appropriate for the pt. in order to be useful as evaluation criteria.

 

evlaution overlaps greatly with the assessment step--both involve data collection.

 

Evlaution data are colelcted after intervention are perfromed to determine whether cleint goals were acheived.


Term

 

Collect Reassessment data

Definition

To minimize confusion, assessments made for the purpose of evaluation are caleld reasessment.

Term

 

 

Judge Goal achievement

Definition

*acheived

 

*Partially achieved

 

*Not acheived

Term

 

Record the Evaluation Statement

Definition

Professional standards require that you record your evaluation.

 

An evaluation statment should include:

1. The conclusion about whether the goal was achieved.

 

2. Reassessment data to support the judgement.

Term

 

Record the Evaluation Statement

(cont'd)

Definition

Evlaution statements are written exactly the same as goals, but the scale number descrines the patients actual status.


Term

 

How do I evaluate Collborative Problems?

Definition

You will collect reassessment data the same as for nursing diagnoses.

 

compare the reassessment data to established norms and dtermine whether data are within an acceptable range

Term

 

Evaluate and Revising the Care plan

(relate outcomes to interventions)

Definition

*The clients ability and motivation to follow directions for treatment.

 

*Avalaibility and support from family and significant others.

 

*Treatments and therapies performed by other healthcare team members

 

*Client fialure to provide complete information during assessment.

Term

 

 

Evaluate and Revising the Care plan

(relate outcomes to interventions)

(cont'd)

Definition

*Clients lack of expereince, knowledge, or ability

 

*Staffing in the instituiton (ration of licensed to unlicnesed caregivers: number of patients for whom a nurse is responsible)

 

*Nurse's physical and mental well-being.

Term

 

Draw Conclusion about problem status

Definition

Goals met: if all goals for a nursing diagnsoses have been met, you can discontinute the care plan for that diagnosis.

 

Goals partially met: If some outcomes are met and others not, you may revise the care plan for that problem.

 

Goals not met: If goals are not met, you should examine the entire plan and review all steps of the nursing process to decide whether to revise the care plan.

Term

 

 

Revise the Care Plan

Definition

Review of assessment: review all initial and ongoing assessment data.

 

Review of diagnosis

 

Review of planning outcomes: if you had added data or revised it.

 

Review of planning interventions: you will probably need to modify nursing orders


Term

 

Revise the Care Plan

(cont'd)

Definition

Review of implementaion: It could be that goals were not met because of failure to implement the nursing orders or because of the manner in which it was implemented.

Term

 

Reflecting Critically about Evaluation

Definition

Inquiring

 

Noticing context

 

Analyzing assumption

 

Reflecting skeptically

Most common erros of evaluation are failure to : evaluate systematically; record the results; use the reassessment data to examine and modify care plan.

Term

 

Evlauting the Quality of Care

Definition

Quality assurance programs


Are specially desigined programs to promote excellence in nursing.

Term

 

Common Errors of Evaluation

Definition

* Failing toevaluate systematically.

 

*Failing to record results.

 

Failing to use reassessment data to re-examine and modify the care plan.

Term

 

Evaluating Quality of Care in a Helath-care Setting

Definition

* Quality Assurance (QA) goal: to evaluate and improve care provided in the health-care setting.

 

QA involves evaluatin of: Structures, outcomes, and processes

Term

 

The final step of implementation

Definition

Documentation

 

* record the nursing activities/interventions and the client repsonse to care

Term
Definition