Chapter 36 Implementing and Evaluating Care

1. Chapter 36Implementing and Evaluating Care

2. 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

3. *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

4. 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.

5. 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 • Develops rapport • *Continuing data collection • Use critical thinking continually to determine if the nursing orders are effective in moving the client toward meeting his/her goal • *Technical skills • Changing a sterile dressing or administering an injection, requires safe and competent performance

6. 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.

7. 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 • Previously established goals and ojectives of the nursing care plan become the standards or criteria by which to measure the clients progress • *Identifying factors contributing to success or failure • Planning for future care

8. 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

9. 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. • As clients meet their goals, new goals are set • The discharge plan is individualized. • Healthcare team usually holds a discharge conference with the client to set new goals.

10. Components of Discharge Planning • Equipment needed at home • Dietary needs: Special diet • *Medications to be taken at home • Resources • Emergency response: Danger signs • Activity • *Follow-up • **Primary nurse is responsible for seeing that the client or family has the necessary discharge instructions • Document instructions and special precautions