IMPLENTING AND EVALUATION  Documenting nursing activities

 Implementing  Evaluation
- Action phase in which the - Fifth nursing process
nurse performs the nursing - Planned, ongoing, purposeful
intervention activity in which clients and
- Consists of doing and health care professionals
documenting the activities determine:
that are specific nursing  Client’s progress
actions needed to carry out towards achievement
the nurse intervention of goals/outcomes
IMPLEMENTING SKILLS  Effectiveness of the
nursing care plan
 Cognitive Skills (intellectual)
Five Components:
- Include problem solving,
decision making, critical  Collecting data related to the desired
thinking, clinical reasoning, outcomes
and creativity  Comparing the data with desired
 Interpersonal Skills outcomes
- All of activities, verbal and  Relating nursing activities to
nonverbal, people use when outcome
interacting directly with one  Continuing, modifying, or terminating
another the nursing care plan
- Nurses use therapeutic
communication to  Evaluation Statement
understand the client and in - Consist of conclusion and
turn be understood supporting data
 Technical Skills  Conclusion
- Purposeful “hands-on” skills - Statement that the
- Require knowledge and goal/desired outcome was
frequently manual dexterity met, partially met, or not met
 Psychomotor Skills  Supporting Data
- Refers to physical actions - List of client responses that
that are controlled by the support the conclusion
mind, not by reflex
EVALUATING THE QUALITY OF
PROCESS OF IMPLEMENTING (5) NURSING CARE
 Reassessing the client o An essential part of professional
 Determining the nurse’s need for accountability
assist
 Implementing the nursing  Quality Assurance Program
intervention - Ongoing, systematic process
 Supervising the delegated care designed to evaluate and
 promote excellence in the - Uses a systematic approach
health care provided to with the intention of
clients improving the quality of care
 Structure Evaluation rather than ensuring the
- Focuses on the setting in quality care
which care is given
NURSING AUDIT
- Structural standards describe
desirable environmental and  Audit
organizational characteristics - Refers to the examination or
that influence care such as review of records
equipment and staffing
 Retrospective Audit
 Process Evaluation
- Evaluation of a client’s record
- Focuses on how the care
after discharge
was given - Retrospect = relating to past
- Focus on the manner in events
which nurses uses the
 Concurrent Audit
nursing process
- Evaluation of a client’s health
 Outcome Evaluation
care while the client is still
- Focuses on demonstrable
receiving care form the
changes in the client’s health agency
status as a result of nursing
 Peer Review
care
- Appraise the quality of care
QUALITY IMPROVEMENT or practice performed by
other equally qualified nurses
 Sentinel Event  Individual Review
- Unexpected occurrence - Focuses on the performance
involving death or serious of an individual nurse
physical or psychological  Nursing Audit
injury or the risk thereof - Focuses on evaluating
 Root Cause Analysis nursing care through the
- Process for identifying the review of records
factors that bring about
deviations in practices that
lead to the event
- It focuses on primarily on
systems and processes, not
individual performance
 Quality Improvement
- Follows client care rather
organizational structure
- Focuses on process rather
than individuals