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14. Implementing and Evaluating LEARNING OUTCOMES After Completing This Chapter,

14. Implementing and Evaluating LEARNING OUTCOMES After Completing This Chapter,

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14. Implementing and EvaluatingLEARNING 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.
Differentiate quality improvement from quality assurance.
9.
Name the two components of an evaluation statement.
10.
Describe three components of quality evaluation: structure, process, and outcomes.KEY TERMSaudit,
 
cognitive skills,
 
concurrent audit,
evaluating,
evaluation statement,
implementing,
 
interpersonal skills,
 
outcome evaluation,
 
process evaluation,
quality-assurance (QA) program,
 
quality improvement (QI),
 
retrospective audit,
 
root cause analysis,
 
sentinel event,
 
structure evaluation,
 
technical skills,
 
INTRODUCTION
The nursing process is action oriented, client centered, and outcome directed. After developing a planof care based on the assessing and diagnosing phases, the nurse implements the interventions andevaluates the desired outcomes. On the basis of this evaluation, the plan of care is either continued,modified, or terminated. As in all phases of the nursing process, clients and support persons areencouraged to participate as much as possible.
IMPLEMENTING
In the nursing process, implementing is the action phase in which the nurse performs the nursinginterventions. Using NIC terminology,
consists of doing and documenting theactivities that are the specific nursing actions needed to carry out the interventions. The nurse performs or delegates the nursing activities for the interventions that were developed in the planningstep and then concludes the implementing step by recording nursing activities and the resulting clientresponses.Although the nurse may act on the client's behalf (e.g., referring the client to a community healthnurse for home care), professional standards support client and family participation, as in all phases of 
 
the nursing process. The degree of participation depends on the client's health status. For example, anunconscious man is unable to participate in his care and therefore needs to have care given to him. Bycontrast, an ambulatory client may require very little care from the nurse and carry out health careactivities independently.
Relationship of Implementing to Other Nursing Process Phases
The first three nursing process phases
  
assessing, diagnosing, and planning
  
 provide the basis for thenursing actions performed during the implementing step. In turn, the implementing phase provides theactual nursing activities and client responses that are examined in the final phase, the evaluating phase. Using data acquired during assessment, the nurse can individualize the care given in theimplementing phase, tailoring the interventions to fit a specific client rather than applying themroutinely to categories of clients (e.g., all clients with pneumonia).While implementing nursing care, the nurse continues to reassess the client at every contact, gatheringdata about the client's responses to the nursing activities and about any new problems that maydevelop. A nursing activity on the client's care plan for the NIC intervention
 Airway Management 
might read "Auscultate breath sounds q4h." When performing this activity, the nurse is both carryingout the intervention (implementing) and performing an assessment. Some routine nursing activitiesare, themselves, assessments. For example, while bathing an elderly client, the nurse observes areddened area on the client's sacrum. Or, when emptying a urinary catheter bag, the nurse measures200 mL of offensive smelling, brown urine.
Implementing Skills
To implement the care plan successfully, nurses need cognitive, interpersonal, and technical skills.These skills are distinct from one another; in practice, however, nurses use them in variouscombinations and with different emphasis, depending on the activity. For instance, when inserting aurinary catheter the nurse needs cognitive knowledge of the principles and steps of the procedure,interpersonal skills to inform and reassure the client, and technical skill in draping the client andmanipulating the equipment.The
(intellectual skills) include problem solving, decision making, critical thinking,and creativity. They are crucial to safe, intelligent nursing care (seeChapter 10).
are all of the activities, verbal and nonverbal, people use when interactingdirectly with one another. The effectiveness of a nursing action often depends largely on the nurse' sability to communicate with others. The nurse uses therapeutic communication to understand theclient and in turn be understood. A nurse also needs to work effectively with others as a member of the health care team.Interpersonal skills are necessary for all nursing activities: caring, comforting, advocating, referring,counseling, and supporting are just a few. Interpersonal skills include conveying knowledge, attitudes,feelings, interest, and appreciation of the client's cultural values and lifestyle. Before nurses can behighly skilled in interpersonal relations, they must have self-awareness and sensitivity to others (seeChapters 25and39).
are purposeful "hands-on" skills such as manipulating equipment, giving injections, bandaging, moving, lifting, and repositioning clients. These skills are also called tasks, procedures, or  psychomotor skills. The term
 psychomotor 
refers to physical actions that are controlled by the mind,not reflexive.
 
Technical skills require knowledge and, frequently, manual dexterity. The number of technical skillsexpected of a nurse has greatly increased in recent years because of the pervasive use of technology,especially in acute care hospitals.
Process of Implementing
The process of implementing (see Figure 14-1) normally includes the following:
Reassessing the client
Determining the nurse's need for assistance
Implementing the nursing interventions
Supervising the delegated care
Documenting nursing activities
Reassessing the Client
Just before implementing an intervention, the nurse must reassess the client to make sure theintervention is still needed. Even though an order is written on the care plan, the client's conditionmay have changed. For example, a client has a nursing diagnosis of 
 Disturbed Sleep Pattern
related toanxiety and unfamiliar surroundings. During rounds, the nurse discovers that she is sleeping andtherefore defers the back massage that had been planned as a relaxation strategy. New data may indicate a need to change the priorities of care or the nursing activities. For example, anurse begins to teach a client who has diabetes, how to give himself insulin injections. Shortly after  beginning the teaching, the nurse realizes that he is not concentrating on the lesson. Subsequentdiscussion reveals that he is worried about his eyesight and fears he is going blind. Realizing that theclient's level of stress is interfering with his learning, the nurse ends the lesson and arranges for a primary care provider to examine the client's eyes. The nurse also provides supportive communicationto help alleviate the client's stress.
Determining the Nurse's Need for Assistance
When implementing some nursing interventions, the nurse may require assistance for one or more of the following reasons:
The nurse is unable to implement the nursing activity safely or efficiently alone (e.g., ambulating anunsteady obese client).
Assistance would reduce stress on the client (e.g., turning a person who experiences acute pain whenmoved).
The nurse lacks the knowledge or skills to implement a particular nursing activity (e.g., a nurse whois not familiar with a particular model of traction equipment needs assistance the first time it isapplied).
Implementing the Nursing Interventions
It is important to explain to the client what interventions will be done, what sensations to expect, whatthe client is expected to do, and what the expected outcome is. For many nursing activities it is alsoimportant to ensure the client's privacy, for example by closing doors, pulling curtains, or draping theclient. The number and kind of direct nursing interventions are almost unlimited. Nurses alsocoordinate client care. This activity involves scheduling client contacts with other departments (e.g.,laboratory and x-ray technicians, physical and respiratory therapists) and serving as a liaison amongthe members of the health care team.

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