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Implementation and Evaluation

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Title: Implementation and Evaluation

1
Transition to Registered Nursing

Implementation and Evaluation
West Coast University
Week 5

2
Objective

Developing nursing actions
Execute interventions
Ongoing assessment
Evaluating the plan of care

3
Implementation

Action begins
Execute interventions
Ongoing assessment

4
Characteristics Of Implementation

Meeting clients needs
Action resulting in
health promotion
prevention of illness
restoration of health
Needs rationale to validate nursing actions
Done in APA for WCU Standardized Care Plan

5
Characteristics of Implementation

Ongoing monitoring
Physical assessment
Communication
Observation
Recording and reporting

6
Characteristics of Implementation

Independent Nursing Function
Dependent Nursing Function
Collaboration

7
Documentation

Documentation
Reflects health status
Response to care

8
Guidelines for Documentation

Document on appropriate client record.
Verify clients name before entries are
documented.
Each page of record should include
identification.
Document as soon as client encounter is
concluded.
Follow institutional guidelines on frequency of
charting.
Write legibly.

continues
9
Guidelines

Write in permanent ink. Black is usually
preferred.
Date and time each entry.
Sign each entry with your full name and
credentials.
If an error is made while documenting, draw one
single line through entry.
Date, time, and sign all corrections.

continues
10
Guidelines

Never erase or use correction fluid on entry
corrections.
Document thoroughly and precisely, in consecutive
order.
Identify documentation entries that are out of
time sequential order. Label as late entry by
entry time.
Document in a complete but concise manner by
using phrases and abbreviations as appropriate.

continues
11
Guidelines

Document telephone calls made or received
relating to clients care.
Date and time each entry
Sign each entry with your full name and
professional credentials
Use quotation marks to indicate direct client
responses (e.g. I feel lousy).

continues
12
Guidelines

Never change another persons entry, even if
incorrect.
Never leave a space between entries or leave a
partial space midline.
Draw one single line from end of your entry to
end of line and initial.

13
Confidentiality

Required by law
Ethical responsibility

Evaluation

15
Evaluation

Evaluation
A look at results
Ongoing step
Critical analysis
Client evaluation
Goals/expected outcomes evaluation

16
Evaluation Purpose

To estimate effectiveness of care
To estimate quality of care
To estimate client responses
To determine if the care plan is working
To determine how well the care plan is working

17
Characteristics of Evaluation

Ongoing
Continues as long as care is provided
Client responses are compared
Focuses on relationship
Success of plan is judged

18
Evaluative Questions

Were the expected outcomes achieved?
Is the plan appropriate?
Should the plan be modified or terminated?
Were goals specific, measurable and realistic?
Were nursing diagnoses relevant?
Was assessment thorough and accurate?
Did the client and family participate in priority
problem identification and goal setting?

19
Review of Goals and Expected Outcomes