IMPLEMENTING NURSING CARE. EVALUATION.

IMPLEMENTATION

Implementation, the fourth step in the nursing process, involves the execution of the nursing plan of care derived during the planning phase of the nursing process. It involves completion of nursing activities to accomplish predetermined goals and to make progress toward achievement of specific outcomes. The execution of the implementation phase of the nursing process, as with the other phases of the process, requires a broad base of clinical knowledge, careful planning, critical thinking and analysis, and judgment on the part of the nurse.

Discusses the purposes of implementation, the specific skills associated with effectively implementing the nursing plan of care, and the activities involved in this process. Although identified as the fourth step of the nursing process, the implementation phase begins with assessment and continually interacts with the other steps in the process to reflect the changing needs of the client and the response of the nurse to those needs.

REQUIREMENTS FOR EFFECTIVE IMPLEMENTATION

The implementation phase of the nursing process requires cognitive (intellectual), psychomotor (technical), and interpersonal skills. These skills serve as competencies through which effective nursing care can be delivered and are used either in conjunction with each other or individually as required by the client and the specific needs of the situation.

Cognitive skills enable nurses to make appropriate observations, understand the rationale for the activities performed, and appreciate the differences among individuals and how they influence nursing care. Critical thinking is an important element within the cognitive domain because it helps nurses to analyze data, organize observations, and apply prior knowledge and experiences to current client situations.

Proficiency with psychomotor skills is necessary to safely and effectively perform nursing activities. Nurses must be able to handle medical equipment with a high

degree of competency and to perform skills such as administering medications and assisting clients with mobility needs (e.g., positioning and ambulating).

The use of interpersonal skills involves communication with clients and families as well as with other health care professionals. The nurse-client relationship is established through the use of therapeutic communication that helps ensure a beneficial outcome for the client’s health status. Interaction between members of the health care team promotes collaboration and enhances holistic care of the client.

IMPLEMENTATION ACTIVITIES

Nursing implementation activities include:

• Ongoing assessment

• Establishment of priorities

• Allocation of resources

• Initiation of nursing interventions

• Documentation of interventions and client response.

These activities are interactive and each is discussed in further detail.

ONGOING ASSESSMENT

The nursing plan of care is based on the initial assessment data collected by the nurse and the nursing diagnoses derived from those data. Because a client’s condition can change rapidly, or new data may become available through interaction with the client, ongoing assessment is necessary to validate the relevance of proposed interventions. Goals, expected outcomes, and interventions may need to be altered as new data are collected or progress toward outcomes is evaluated.

Although a focused assessment should be completed during the initial interaction with the client, continuous observations during the implementation process allow for adaptations to be made to better individualize care.

It is not unusual for nursing diagnoses to change or to be resolved in a short period of time. For example, the nursing care plan for Mrs. Cline, a preoperative client, might include an intervention to teach her about the use of a patient-controlled analgesia (PCA) pump. As the use of this equipment is being demonstrated, the nurse observes that Mrs. Cline is unable to depress the button easily with the fingers of her right hand. Mrs. Cline informs the nurse that she forgot to mention that her joints swell occasionally and she has very little strength in her hand during these times. This information is essential for both developing a nursing diagnosis concerning Mrs. Cline’s impaired physical mobility and determining appropriate teaching methods for use of the PCA pump.

Ongoing assessment demands attention to verbal and nonverbal cues from the client and requires knowledge of expected responses to specific interventions. If nurses observe that responses are different from those expected, this assessment data can lead to a change in expected outcomes and accompanying interventions.

Ongoing assessment is of equal importance in home health care or extended care settings when contact with skilled health care providers might occur less frequently and the length of time that the care is required varies (see the accompanying display). The nurse’s assessment and clinical judgment often determine whether the client needs continued care or referral to other health care providers.

ESTABLISHMENT OF PRIORITIES

Following ongoing assessment and review of the problem list, priorities are determined for implementation of care. Priorities are based on:

• Which problems are deemed most important by the nurse, the client, and family or significant others.

• Activities previously scheduled by other departments (e.g., surgery, diagnostic testing)

• Available resources

The change-of-shift report can also be a valuable tool in determining priorities. A client’s condition and variables in the clinical setting can change quickly and frequently—especially in acute care settings—requiring that the nurse exercise strong clinical judgment and maintain flexibility in organizing care. For example, the nursing care plan for Mr. Jenkins, who had hip replacement surgery, might reflect a priority nursing diagnosis of Impaired Physical Mobility with interventions focused toward learning to ambulate. When the nurse listens to Mr. Jenkins’ breath sounds on a particular morning, it is noted that his breathing is more labored and crackles can be auscultated in the lung bases. This assessment is noted on the change-of-shift report, and the priorities of interventions change to focus on this new development.

Time management is important whether the nurse is caring for one client or a group of clients. It is helpful to make a list of tasks that need to be accomplished throughout the day and to create a worksheet outlining a target time for these activities. Those activities with specified times for completion should be scheduled first. For example, medications usually allow a narrow time frame for administration and must be scheduled at specific times on the worksheet. An example of a worksheet that outlines a plan for activities is shown in Table 9-1.

The time allotted for activities depends on the complexity of the task and the amount of assistance required by the client. An example of a worksheet for a group of clients is presented in Table 9-2.

ALLOCATION OF RESOURCES

Before implementing the nursing plan of care, the nurse reviews proposed interventions to determine the level of knowledge and the types of skills required for safe and effective implementation. The assessment provides data for determining if an activity can be performed independently by the client, can be completed with assistance from family, or requires assistance of health care personnel.

Delegation of Tasks

The registered nurse is legally responsible for all nursing care given. Whereas some interventions are complex and require the knowledge and skills of a registered nurse, other interventions are relatively simple and can be delegated to assistive personnel.

Delegation is the process of transferring a selected nursing task in a situation to an individual who is competent to perform that specific task. It must be remembered that, although some activities can be assigned to other health care personnel, the registered nurse remains accountable for appropriate delegation and supervision of care provided by these individuals. In general, registered nurses are authorized by law to both provide nursing care to clients directly and supervise and instruct others to deliver this care. Further, the registered nurse is empowered to delegate selected tasks to either licensed or unlicensed nursing personnel (seeFigure 9-1).

Decisions about delegation are guided by the needs of the client, the number and type of available personnel, and the nursing management system of the unit or agency. In performing delegated tasks, nursing students must either determine if the intervention is one that they have performed with supervision and can safely accomplish independently or is one for which assistance is needed.

The first consideration in determining the most appropriate nursing personnel to administer care is client safety. Nurse practice acts dictate to some extent which tasks can be legally delegated. For example, administration of blood or blood products is not an act that can be legally delegated to licensed practical nurses or unlicensed assistive personnel in most states.

Other activities, such as assisting clients with activities of daily living (ADL, those activities performed by a person usually on a daily basis), ordering supplies, or transcribing orders, can often be safely delegated to other personnel.

If delegation of a particular activity is legally allowed, the nurse should validate the knowledge and skill level of personnel before delegation. If uncertain about the level of competence of an individual to perform an activity, the nurse should not delegate the task even though it might be legally performed by that level of personnel.

The registered nurse is held accountable to delegate only such care that can safely be done by the other individual and would be performed with the same level of competency and respect for state laws and regulations as would be evident in the nurse’s performance of this care.

Types of Management Systems

Wise use of resources dictates that tasks be assigned to the most cost-effective level of personnel who can safely and proficiently perform the activity. The nursing management system often determines the numbers and types of personnel available. Changes in health care delivery in recent years have resulted in an increasing emphasis on cost containment and have subsequently created several unique management models. The redesign of the workplace in many health care agencies has included cross-training of employees, with nurses frequently assuming responsibilities formerly assigned to other health care providers. For example, nurses might draw blood for laboratory tests, perform electrocardiograms, or administer respiratory treatments, as care is focused around the client rather than the various departments in the agency. Nurses in community health settings have traditionally exercised a variety of roles in their practice.

As health care delivery continues to evolve in this country, a variety of innovative approaches will emerge to better meet the needs of clients. The most common management systems currently used include functional nursing, team nursing, primary nursing, total client care, modular nursing, and case management.

FUNCTIONAL NURSING

The functional nursing approach divides care into tasks to be completed and uses various levels of personnel depending on the complexity of the assignment. Each member of the staff performs his or her assigned task for each client. For example, one nurse may assess each client and document findings and another may give all medications and treatments. Another nurse may be assigned to complete client teaching or discharge planning (process that enables the client to resume self-care activities before leaving the health care environment).

One nursing assistant might serve all trays and collect intake and output records for each client while another is responsible for giving baths or making beds. The advantage of this system is that a large number of clients can be cared for by a relatively small number of personnel. In addition, it allows the use of less skilled (and less expensive) personnel for some tasks and allows personnel to be used in areas for which they have special knowledge or skill. However, this system can also result in fragmented and depersonalized care and may invite omissions in care because no one person is responsible for the total care of the client.

TEAM NURSING

The team nursing approach uses a variety of personnel (professional, technical, and unlicensed assistants) in the delivery of nursing care. The registered nurse is leader of the team and is responsible for supervision of the team, as well as planning and evaluating the results of caregiving activities. This management system uses professional nurses for skilled observations and interventions and provision of direct care to acutely ill clients, while licensed practical nurses care for less acutely ill clients, and nursing assistants are responsible for serving trays, making beds, and assisting the nurses with other tasks. This management system is frequently used because it is cost-effective and provides more individualized care than the functional approach.

PRIMARY NURSING

In the primary nursing management system, the professional nurse assumes full responsibility for total client care for a small number of clients. Although care may be delegated to nurse associates for shifts when the primary nurse is not in attendance, the primary nurse maintains responsibility for total client care 24 hours a day (see Figure 9-2).

The primary nurse sets health care goals with the client and plans care to meet those goals. The principal advantage of this approach is the continuity of care inherent in the system. Primary nursing is most effective with a total staff of registered nurses, which makes this system expensive to maintain.

TOTAL CLIENT CARE AND MODULAR NURSING

Total client care and modular nursing are variations of primary nursing. Although these systems imply that one nurse is responsible for all the care administered to a client, responsibility for the client actually changes from shift to shift with the assigned caregiver. This system uses both registered nurses and licensed practical nurses; the registered nurses are assigned to more complex client situations. A unit manager or charge nurse typically coordinates activities on the unit. Modular nursing attempts to assign caregivers to a small segment or “module” of a nursing unit, ensuring that clients are cared for by the same personnel on a regular basis.

CASE MANAGEMENT

In the case management system, the nurse assumes responsibility for planning, implementing, coordinating, and evaluating care for a given client, regardless of the client’s location at any given time. This approach is often used when care is complex and a number of health care team members are involved in providing care. Generally, a case management plan, or critical pathway, is developed (based on the norm or typical course of the condition), and the nurse evaluates the progress of the client in relation to what is expected, investigating and following up on any variance in the time required or the amount of improvement noted. Although the case load for the individual nurse might be smaller (thus making this approach expensive), continuity of care and collaboration are enhanced.

NURSING INTERVENTIONS

After reviewing the client’s current condition, verifying priorities, and examining resources, the nurse should be ready to initiate nursing interventions. A nursing intervention is an action performed by the nurse that help the client to achieve the results specified by the goals and expected outcomes. All interventions must conform to standards of care.

Nurses should understand the reason for any intervention, the expected effect, and any potential problems that may result. Understanding the reason for a nursing intervention is the hallmark of a professional nurse, in that the nurse is using logic and/or scientific reasoning as the basis of practice.

Nursing interventions are a blend of science (rational acts) and art (intuitive actions). It is important for novice nurses to identify the rationale (the fundamental principle) of all interventions in order to implement theory-based practice. Prior to implementation, it is necessary to determine exactly:

• What is to be done

• How it is to be done

• When it should be done

• Who will do it

• How long it should be done

Interventions are determined by and directed toward the cause of the problem or factors contributing to the nursing diagnosis and may vary for clients with similar nursing diagnoses depending on realistic expected outcomes for the individual. Consideration should be given to client preferences, the developmental level of the client, and availability of resources. In addition, the health care practitioner’s orders often have an impact on nursing interventions by imposing restrictions on factors such as diet or activity.

TYPES OF NURSING INTERVENTIONS

Nursing interventions are written as orders in the care plan and may be nurse-initiated, health care practitioner-initiated, or derived from collaboration with other health care professionals. These interventions can also be categorized as independent, dependent, or interdependent, depending on the authority required for initiation of the activity.

Interventions can be implemented on the basis of standing orders or protocols. A standing order is a standardized intervention written, approved, and signed by a health care practitioner that is kept on file within health care agencies to be used in predictable situations or in circumstances requiring immediate attention. Nurses can implement standing orders in these situations after they have assessed the client and identified the primary or emerging problem. For example, nurses in an ambulatory clinic or home health care agency may have standing orders for administering certain medications or ordering laboratory tests when indicated, or a health care practitioner may establish standing orders on an inpatient unit that specify certain medications that can be administered for common complaints such as headache.

Table 9-3 provides an example of standing orders used for client preparation for a barium enema.

A protocol is a series of standing orders or procedures that should be followed under certain specific conditions.

They define what interventions are permissible and under what circumstances the nurse is allowed to implement the measures. Health care agencies or individual health care practitioners frequently have standing orders or protocols for client preparation for diagnostic tests or for immediate interventions in life-threatening circumstances.

These protocols prevent needless duplication of writing the same orders repeatedly for different clients and often save valuable time in critical situations.

NURSING INTERVENTIONS CLASSIFICATION

The Iowa Intervention Project has developed a taxonomy of nursing interventions that includes both direct and indirect activities directed toward health promotion and illness management (Iowa Intervention Project, 1993). This taxonomy, the Nursing Interventions Classification (NIC), is a standardized language system that describes nursing interventions performed in all practice settings.

“NIC offers a standardized language that communicates the nature and worth of the work we do. Without it, nursing will remain in jeopardy” (Eganhouse, ComiMcCloskey, & Bulecheck, 1996). NIC is a method for linking nursing interventions to diagnoses and client outcomes (McCloskey, Bulechek, & Eoyang, 1999).

The format for each intervention is as follows: label name, definition, a list of activities that a nurse performs to carry out the intervention, and a list of background readings (McCloskey & Bulechek, 1996) (See Table 9-4).

NIC offers standardized language for research on nursing interventions and is a promising tool for determining reimbursement for nursing services.

NURSING INTERVENTION ACTIVITIES

Nursing interventions include:

• Assisting with ADL

• Delivering skilled therapeutic interventions

• Monitoring and surveillance of response to care

• Teaching

• Discharge planning

• Supervising and coordinating nursing personnel

Implementing nursing interventions requires that consideration be given to client rights, nursing ethics, and the legal implications associated with providing care.

Clients have the right to refuse any intervention. However, the nurse must explain the rationale for the intervention and possible consequences associated with refusing treatment. If the intervention refused was health care practitioner-initiated, the health care practitioner should be informed of the refusal of care. Ethical standards require that clients be afforded privacy and confidentiality. Matters related to a client’s condition and care should be discussed only with individuals directly involved with the client’s care, and any discussion should be held in a location where information cannot be overheard by visitors or bystanders. From a legal standpoint, the nurse must ensure that the authority for prescribing any intervention has been satisfied and that applicable standards of care are maintained during implementation of all nursing interventions.

ACTIVITIES OF DAILY LIVING

Clients frequently need assistance with ADL such as bathing, grooming, ambulating, eating, and eliminating.

The goal for most clients is to return to self-care or to regain as much autonomy as possible. The nurse’s role is to determine the extent of assi stance needed and to provide support for ADL while at the same time fostering independence. Ongoing assessment is important for determining the appropriate balance between ensuring safety and promoting independence. For example, maintaining personal grooming is important for purposes of hygiene and comfort as well as for promoting self-esteem.

The nurse must always provide privacy when assisting clients with personal hygiene. If these tasks are assigned to other personnel, adequate supervision is imperative to ensure compliance with these principles.

THERAPEUTIC INTERVENTIONS

Therapeutic nursing interventions are those measures directed toward resolution of a current problem and include activities such as administration of medications and treatments, performing skilled procedures, and providing physical and psychological comfort. Written orders must be verified before implementing interventions requiring prescriptive authority. Reassessment of the client is also needed to determine if the intervention remains appropriate. In addition, a nurse must also understand the rationale, expected effects, and possible complications that could result from any intervention.

MONITORING AND SURVEILLANCE

Observation of the client’s response to treatment is an integral part of implementation of any intervention. Monitoring and surveillance of the client’s progress or lack of progress are essential in determining the effectiveness of the plan of care and for detection of potential complications. Specific interventions require specific monitoring activities; however, typical monitoring activities include observations such as vital signs measurement, cardiac monitoring, and recording of intake and output.

TEACHING

A key element in health promotion and illness management is the counseling of clients to help them modify their behaviors in response to potential health risks and actual health alterations. As part of this teaching process, nurses must also discuss the rationales for the interventions that are included in the nursing plan of care.

Numerous opportunities arise every day for informal teaching related to client care. For example, teaching clients about the medications they are taking and possible side effects should occur routinely as medications are administered. Similarly, as nurses perform assessment activities, the sharing of observations with the client can be informative in terms of what characteristics are desirable and what observations are sources of concern.

This knowledge can be valuable to a client when self-monitoring.

Effective teaching requires insight into the client’s knowledge base and readiness to learn. Realistic teaching goals and learning outcomes should be set on the basis of these factors. It is also desirable to include the family or significant others in teaching plans. A suitable learning environment should be created that is nonthreatening and allows active participation by the client. Nurses should be careful to use terminology easily understood by the client. It is important that learning outcomes are validated to be sure that clients can safely and effectively care for themselves on discharge.

DISCHARGE PLANNING

Preparation for discharge begins at the time of admission to a health care facility. As the average length of stay in acute care settings continues to decrease, early discharge planning becomes imperative. Expected outcomes dictate the type of planning required and the interventions necessary to attain the desired outcomes.

Interventions directed toward discharge planning include activities such as teaching and consultation with other agencies (e.g., home health, rehabilitation facilities, nursing homes, social services) concerning followup care. Teaching related to any changes in diet, medications, or lifestyle must be implemented; any barriers or problems in the home environment must be resolved before discharge. Some agencies employ personnel with the primary responsibility of teaching or discharge planning for groups of clients; however, the nurse who is caring for the individual client is also responsible for ensuring that all appropriate interventions have been implemented before discharge.

SUPERVISION AND COORDINATION OF PERSONNEL

The management style and type of facility, as well as the needs of the client, determine the scope of interventions associated with supervision and coordination of client care. In a health care facility in which nurses are assigned clients within a total client care management system, responsibilities for supervision might be minimal, whereas facilities that use a variety of ancillary personnel for certain client activities might require a large percentage of time devoted to supervision of care. In home health care, for example, the primary role of the professional nurse might be supervision of personnel who provide assistance with ADL. Although a nurse might delegate certain tasks to other personnel, it is still the nurse’s responsibility to ensure that the task was completed according to standards of care and to note the response of the client in order to evaluate progress toward expected outcomes.

Regardless of management style or type of facility, coordination of client activities among various health care providers remains the nurse’s responsibility. For example, in acute care settings, the nurse needs to coordinate client activities around the schedule of diagnostic tests or physical therapy. Scheduling of procedures, therapy, treatments, and medications for a number of clients often requires considerable organizational skills, creativity, and resourcefulness.

EVALUATING INTERVENTIONS

An important step to assure the delivery of quality care is evaluation of nursing interventions. One approach to determining the efficacy of nursing interventions is by evaluating clients’ achievement of expected outcomes.

The Nursing Intervention Classification (NIC), previously described in this chapter, provides a systematic method for linking nursing activities to client outcomes. When treatment can be shown to directly improve client outcomes, both nursing and health care consumers benefit. Another taxonomy, the Nursing Outcomes

Classification (NOC) has been specifically designed to evaluate nursing interventions. NOC provides a common language for measuring client responses to nursing interventions.

DOCUMENTATION OF INTERVENTIONS

Communication concerning implementation of interventions must be provided through written documentation and should also be verbally conveyed when responsibility of the client’s care is transferred to another nurse.

The nurse is legally required to record all interventions and observations related to the client’s response to treatment.

This not only provides a legal record but also allows valuable communication with other health care team members for continuity of care and for evaluating progress toward expected outcomes. In addition, written documentation provides data necessary for reimbursement for services and tracking of indicators for continuous quality improvement.

The recording of information can be in the form of either checklists, flow sheets, or narrative summaries. A complete description must be provided if there are any deviations from the norm or if any changes have occurred.

Verbal interaction among health care providers is also essential for communicating current information about clients. Nurses who delegate the delivery of client care to assistive personnel must be careful to elicit their feedback related to activities completed and the client’s response to any interventions. In addition, assistive personnel should be alerted as to what additional data are meaningful, and these data should be conveyed to the nurse responsible for the client’s care. For example, if a nursing assistant observes that Mrs. Robbins, hospitalized with a deep vein thrombosis of the left leg, is having difficulty swallowing and has eaten very little, this information should be reported to the nurse. This is especially important if the behavior is a new occurrence and not a part of the established problem list, because the nurse might not otherwise seek this information.

Communication between nurses generally occurs at the change of shift, when the responsibility for care changes from one nurse to another. Nursing students must communicate relevant information to the nurse responsible for their clients when they leave the unit. Information that should be shared in the verbal report includes:

• Activities completed and those remaining to be completed

• Status of current relevant problems

• Any abnormalities or changes in assessment

• Results of treatments (i.e., client response)

• Diagnostic tests scheduled or completed (and results)

All communication—written and/or verbal—must be objective, descriptive, and complete. The communication includes observations rather than opinions and is stated or written so that an accurate picture of the client is conveyed. For example, if it is noted that a client is less alert today than yesterday, the behavior that led to that conclusion should be documented. This observation can be objectively and descriptively communicated by the statement: “Does not respond unless firmly touched; quickly returns to sleep.” This description results in a more complete picture of the client than simply stating:

“Less alert today.” Thorough and detailed communication of implementation activities is fundamental to ensuring that client care and progress toward goals can be adequately evaluated.

KEY CONCEPTS

• The implementation step of the nursing process is directed toward meeting client needs and results in health promotion, prevention of illness, illness management, or health restoration and also involves delegation of nursing care activities to assistive personnel and documentation of the implementation activities performed.

• Implementation requires cognitive, psychomotor, and intellectual skills to accomplish goals and make progress toward expected outcomes.

• Implementation activities include ongoing assessment, establishment of priorities, allocation of resources, initiation of specific nursing interventions, and documentation of interventions and client responses.

• Ongoing assessment is necessary for determining effectiveness of interventions and for detection of new problems.

• Changing variables in clients and the environment demand clinical judgment and flexibility in organizing care.

• Time management skills are essential in implementing client care.

• The nurse maintains responsibility for care delegated to other health care personnel.

• The most common management systems currently used include functional nursing, team nursing, primary nursing, total client care, modular nursing, and case management.

• Interventions can be nurse-initiated, health care practitioner-initiated, or collaborative in origin, and thus are considered dependent, independent, or interdependent.

• Nursing Interventions Classification (NIC) is a system for sorting, labeling, and describing nursing interventions.

• Nursing interventions include assisting with activities of daily living, skilled therapeutic interventions, monitoring and surveillance of response to care, teaching, discharge planning, and supervision and coordination of nursing personnel.

• Communication concerning interventions should be provided verbally and in writing.

CRITICAL THINKING ACTIVITIES

1. Label each of the following nursing interventions as dependent (dep.), independent (ind.), or interdependent (int.).

_____ a. Applying a heating pad to a shoulder for 20 minutes

_____ b. Administering a pain medication as needed following surgery

_____ c. Turning a client with impaired mobility every 2 hours

_____ d. Teaching a client about side effects of a medication

_____ e. Assisting a client with oral care

_____ f. Sending an order for a diagnostic laboratory test

_____ g. Reviewing and conveying abnormal lab test results

_____ h. Starting intravenous fluids

2. List five implementation activities and give an example of each.

3. List two reasons for documentation of client care.

4. Situation: Mary Long, age 42, has come to the clinic because of recurrent chest pains (although symptom free at this time). Although there is a strong family history of heart disease, she has no personal history of heart problems. She is approximately 60 lb overweight and you determine that her lifestyle is rather sedentary and her diet high in fat content.

She lives at home with her husband. Her children no longer live at home. Although she works part-time as a receptionist, her favorite activity is cooking.

Her health care practitioner mentions diet, exercise, and weight control as long-term activities, orders a series of tests to be done as an outpatient, and gives her a prescription for nitroglycerin tablets for chest pain.

What interventions do you think will be necessary and appropriate for Mrs. Long? How would you organize priorities for Mrs. Long?

5. Consider your most recent clinical experience. How could you have organized your time more effectively? Apply these same time management principles to your study time. How could you arrange your time more efficiently?

6. The next time you are in a clinical agency, examine your client’s record for the previous 8 hours. Does it provide a vivid and accurate description of the client? How could the written documentation be improved?

7. Ask a nurse what activities occupy most of his or her time. What activities does the nurse most enjoy? What does the nurse least enjoy? Compare this nurse’s perceptions with your own ideas.

8. How does the Nurse Practice Act in your state address delegation? Does the definition specifically address the registered nurse’s role in supervising other nursing personnel? Licensed practical nurse’s role? Delegation of nursing care to others? Has the Board of Nursing in your state established rules on delegation? If so, what do these rules allow? If not, how is the issue of delegation of nursing care addressed?

9. You are caring for Mr. Sims, who has had a stroke. The care plan includes the following activities and interventions:

• Up in chair at bedside 3 times a day for at least 30 minutes

• Assist bed bath/assist with eating

• CT of head at 10:00 am

• Strengthening exercises per physical therapy at 9:00 am

• Routine medications at 9:00 am and 1:00 pm You are responsible for total client care for Mr. Sims. Write a plan of your activities with Mr. Sims.

EVALUATION.

Evaluation is the fifth step in the nursing process and involves determining whether the client goals have been met, have been partially met, or have not been met. Even though it is the final phase of the nursing process, evaluation is an ongoing part of daily nursing activities that determines the effectiveness of those activities in helping clients achieve expected outcomes.

Evaluation is not only a part of the nursing process, but it is also an integral process in determining the quality of health care delivered. In addition to discussing evaluation as part of the nursing process, this chapter also describes the role of evaluation in delivering quality care.

This lecture discusses the purposes, components, and methods of evaluation. The relationship between evaluation and quality of care is described.

EVALUATION OF CLIENT CARE

Evaluation is the measurement of the degree to which objectives are achieved. Therefore, evaluating the care provided to clients is an essential part of professional nursing. “Evaluation is a planned, systematic process compares the client’s health status with the desired expected outcomes” (Kenney, 1995, p. 195).

The American Nurses Association (1998), in its Standards of Clinical Nursing Practice, designates evaluation as a fundamental component of the nursing process (see the accompanying display).

The purposes of evaluation include:

• To determine the client’s progress or lack of progress toward achievement of expected outcomes

• To determine the effectiveness of nursing care in helping clients achieve the expected outcomes

• To determine the overall quality of care provided

• To promote nursing accountability (discussed later in this chapter)

Evaluation is done primarily to determine whether a client is progressing—that is, experiencing an improvement in health status. Evaluation is not an end to the nursing process, but rather an ongoing mechanism that assures quality interventions. Effective evaluation is done periodically, not just prior to termination of care. Evaluation is closely related to each of the other stages of the nursing process. The plan of care may be modified during any phase of the nursing process when the need to do so is determined through evaluation. Client goals and expected outcomes provide the criteria for evaluation of care.

COMPONENTS OF EVALUATION

Evaluation is a fluid process that is dependent on all the other components of the nursing process. As shown in Figure 10-1, evaluation affects, and is affected by, assessment, diagnosis, outcome identification and planning, and implementation of nursing care.

Table 10-1 shows how evaluation is woven into every phase of the nursing process.

Ongoing evaluation is essential if the nursing process is to be implemented appropriately. As Alfaro- LeFevre (1998) states:

When we evaluate early, checking whether our information is accurate, complete, and up-to-date, we’re able to make corrections early. We avoid making decisions based on outdated, inaccurate, or incomplete information. Early evaluation enhances our ability to act safely and effectively. It improves our efficiency by helping us stay focused on priorities and avoid wasting time continuing useless actions.

There are specific criteria to be used in the process of evaluation. The evaluation criteria must be planned, goal-directed, objective, verifiable, and specific (that is, strengths, weaknesses, achievements, and deficits must be considered).

TECHNIQUES

Effective evaluation results primarily from the nurse’s accurate use of communication and observation skills. Both verbal and nonverbal communication between the nurse and the client can yield important information about the accuracy of the goals and expected planned outcomes and the nursing interventions that have been executed for resolution of the client’s problems. The nurse needs to be sensitive to clients’ willingness or hesitation to discuss their responses to nursing actions and must use the techniques of therapeutic communication to collect all necessary data.

The nurse must be sensitive to changes in the client’s physiological condition, emotional status, and behavior. Because these changes are often subtle, they require astute observational skills on the part of the nurse. Observation occurs through use of the senses. In other words, what the nurse sees, hears, smells, and feels when touching the client all provide clues to the client’s current health status.

SOURCES OF DATA

Evaluation is a mutual process occurring among the nurse, client, family, and other health care providers. Both subjective and objective data are used in evaluating the client’s status. Asking clients to describe how they feel results in subjective data. Objective data consist of observable facts, such as laboratory values and the client’s behavior. When a nurse communicates an assessment of a client’s response to an actual or potential health problem, clients and families are empowered to discuss their concerns and questions. When feedback is given, the nurse must avoid being defensive, because that attitude may cause clients or families to avoid being open and honest. As a result, they may only say what they think the nurse wants to hear or they may completely refuse to participate in the evaluation process.

The nurse’s verbal and nonverbal communication establishes the atmosphere in which clients and families freely share their comments, both positive and negative.

GOALS AND EXPECTED OUTCOMES

The effectiveness of nursing interventions is evaluated by examination of goals and expected outcomes. Goals provide direction for the plan of care and serve as measurements for the client’s progress or lack of progress toward resolution of a problem.

Realistic goals are necessary for effective evaluation. These goals must take into consideration the client’s strengths, limitations, resources, and the time frame for achievement of the objectives. Examples of client strengths are educational background, family support, and financial resources (for instance, money to purchase medications and foods that support the prescribed interventions). Examples of client limitations are delayed developmental level, poverty, and unwillingness to change (lack of motivation).

METHODS OF EVALUATION

The nurse who successfully evaluates nursing care uses a systematic approach that ensures thorough, comprehensive collection of data. Evaluation is an orderly process consisting of seven steps, which are explained here.

ESTABLISHING STANDARDS

Specific criteria are used to determine whether the demonstrated behavior indicates goal achievement. Standards are established before nursing action is implemented. Evaluation of criteria examines the presence of any changes, direction of change (positive or negative), and whether the changes were expected or unexpected.

COLLECTING DATA

Assessment skills are used to gather data pertinent to goals and expected outcomes. The nurse must be proficient in assessment skills for effective, comprehensive evaluation to occur. Evaluation data are collected to answer the following question: Were the treatment goals and expected outcomes achieved?

DETERMINING GOAL ACHIEVEMENT

Data are analyzed to determine whether client behaviors indicate goal achievement. This process is validated through analysis of the client’s response to the specific nursing interventions that are developed in the plan of care. For example, these data can take the form of either physiological responses (such as the client’s being able to cough productively in order to promote effective breathing patterns) or psychosocial responses (such as the client’s being able to verbalize concerns about an impending surgical procedure in order to alleviate anxiety).

RELATING NURSING ACTIONS TO CLIENT STATUS

Nursing interventions are examined to determine their relevance to the client’s needs and nursing diagnoses.

Efficient nursing actions are those that address pertinent client needs and are proven to be primary factors in helping clients appropriately resolve actual or potential problems.

JUDGING THE VALUE OF NURSING INTERVENTIONS

Critical-thinking skills are employed to determine the degree to which nursing actions have contributed to the client’s improved status. These skills enable the nurse to apply an analytical focus to the client’s responses to the nursing interventions and thus to evaluate the benefits of those actions and identify additional opportunities for change.

REASSESSING THE CLIENT’S STATUS

The client’s health status is reevaluated through use of assessment and observation skills. Evaluation focuses on the client’s health status and compares it with baseline data collected during the initial assessment. Omissions or incomplete data within the database are identified so that an accurate picture of the client’s health status is obtained.

MODIFYING THE PLAN OF CARE

If the evaluation data indicate a lack of progress toward goal achievement, the plan of care is modified. These revisions are developed through the following process:reassessment of the client; formulation of more appropriate nursing diagnoses; development of new or revised goals and expected outcomes; and implementation of different nursing actions or repetition of specific actions to maximize their effectiveness (for instance, client teaching).

See the Nursing Checklist for guidelines for evaluating effective application of the nursing process to client care.

Evaluation is performed by every nurse, regardless of the practice setting. For example, the home health nurse evaluates the care provided regularly throughout the client’s relationship with the agency. Evaluation of the home care client is carried out in order to determine whether the care was delivered in an effective and efficient manner, to modify the plan of care as needed, and to decide when the client is ready for discontinuation of home care services. The accompanying display provides an example of evaluation performed by the home health care nurse.

CRITICAL THINKING AND EVALUATION

Evaluation is a critical thinking activity. It is a deliberate mechanism used to analyze and make judgments. Nurses need to remain objective when evaluating client care in order to modify care based on reason rather than emotion. One critical thinking strategy, juxtaposing, is described as “putting the present state condition next to the outcome state in a side-by-side contrast” (Pesut & Herman, 1999, p. 93). Nurses use juxtaposing throughout evaluative activities by comparing client responses to expected behaviors. They make conclusions about whether expected outcomes have been met. In order to make such conclusions, assessment data is needed to determine client progress toward achievement of objectives. Evaluation involves analysis and is much more complex than merely answering questions.

EVALUATION AND QUALITY OF CARE

Evaluation is performed at the individual and institutional levels. For example, individual evaluation focuses on the client’s achievement of goals and also on the individual nurse’s delivery of care. Quality and evaluation are closely related. This section examines the role of evaluation in assuring the delivery of quality health care. Because it is the mechanism used by nurses in determining the need for improvement, evaluation assists in the provision of quality care. The aspects that need to be evaluated to determine the quality of health care are:

• Appropriateness (the care provided adhered to standards and resulted in achievement of goals)

• Clinical outcomes

• Client satisfaction

• Cost-effectiveness

• Access to care

• Availability of resources

Quality management involves constant, ongoing evaluation (monitoring of activities).

ELEMENTS IN EVALUATING THE QUALITY OF CARE

Organizational evaluation examines the agency’s overall ability to deliver quality care. Evaluation can be classified according to what is being evaluated: the structure, the process, or the outcome. Table 10-2 provides an overview of the types of evaluation. Figure 10-2 illustrates the variables to be assessed in each type of evaluation.

STRUCTURE EVALUATION

Structure evaluation is a determination of the health care agency’s ability to provide the services offered to its client population. This type of evaluation focuses on assessing the systems by which nursing care is delivered (Barnum & Kerfoot, 1995). Structure evaluation examines the physical facilities, resources, equipment, staffing patterns, organizational patterns, and the agency’s qualifications for staff. The majority of problems with providing effective health care stems from problems in the structural area. The purpose of structure evaluation is to identify any system errors, which can then be corrected. Structure evaluation involves determining whether client care meets legal and professional standards. A frequently used method to evaluate whether the agency provides care within legal parameters is a review of policy and procedure manuals to check for compliance with regulations.

PROCESS EVALUATION

Process evaluation is the measurement of nursing actions by examination of each phase of the nursing process. This type of evaluation is done to determine whether nursing care was adequate, appropriate, effective, and efficient. Nursing interventions are judged to be effective when use of the action results in the desired outcome. A nursing intervention is determined to be efficient through analysis of the intervention’s cost–benefit ratio (Gillies, 1994). Process evaluation determines the nurse’s ability to establish an environment that promotes the client’s health.

See Table 10-2 for sample questions used during process evaluation.

OUTCOME EVALUATION

Outcome evaluation is the process of comparing the client’s current status with the expected outcomes. This type of evaluation examines all direct care activities that affect the client’s health status. According to Kenney (1995), “Outcome evaluation, though difficult, is the most meaningful way to judge the effectiveness of nursing interventions”.

Outcome evaluation focuses on changes in the client’s health status. A basic question to ask when evaluating the outcome is: Has the expected change occurred? Such changes may include “modifications of symptoms; signs; knowledge; attitudes; satisfaction; skill; and compliance with treatment regimen” (Gillies, 1994, p. 517). Another variable assessed during outcome evaluation is the client’s self-care ability. Has the client demonstrated an improved ability to care for self? Does the client verbalize knowledge related to self-care needs?

See Table 10-2 for suggested approaches to performing outcome evaluation.

NURSING AUDIT

A nursing audit is the process of collecting and analyzing data to evaluate the effectiveness of nursing interventions. A nursing audit can focus on implementation of the nursing process, client outcomes, or both in order to evaluate the quality of care provided. Nursing audits examine data related to:

• Safety measures

• Treatment interventions and client responses to the interventions

• Preestablished outcomes used as basis for interventions

• Discharge planning

• Client teaching

• Adequacy of staffing patterns

Audits are based on components such as institutional policies; federal, state, and local regulations; accreditation standards; and professional standards (see Figure10-3).

Audits assist in identifying strengths and weaknesses that, in turn, provide direction for areas needing revision. Corrective action plans are developed in accordance with the audit results.

PEER EVALUATION

Another method of evaluating quality of care is peer evaluation (also referred to as peer review), the process by which professionals provide to their peers critical performance appraisal and feedback that are geared toward corrective action. According to the ANA (1988):

Peer review in nursing is the process by which practicing Registered Nurses systematically assess, monitor, and make judgments about the quality of nursing care provided by peers, as measured against professional standards of practice.

In 1984, Lucille Joel postulated that peer review is the basis of nursing’s autonomy and self-governance (Joel, 1984). This perspective is still very relevant in today’s health care climate. By evaluating itself, nursing is demonstrating an essential criterion by which professions are recognized. Peer evaluation promotes both

professional and individual accountability. The quality of nursing care is strongly evident to coworkers and nurses who are expected to assess the work of their peers. “Peer review is an essential mechanism for evaluating the judgment and performance of clinical providers” (Wakefield, Helms, & Helms, 1995, p. 11).

Such judgment may result in one of the following outcomes:

• Destructive: Complaints and attacks that undermine morale and cohesiveness

• Constructive: Positive feedback that improves the quality of care

Peer evaluation can be destructive if the parties involved begin to personalize the process, misunderstand the purpose, or deliver feedback in an unfeeling and

nonobjective manner.

Peer evaluation can be threatening when guidelines have not been established for the process and when the assessment focuses on emotions and personalities instead of on behaviors. Conversely, peer evaluation is constructive when the focus remains on quality improvement and encourages the continued growth and learning of all the parties involved. The accompanying display provides principles that promote the use of objective, nonbiased peer evaluation.

EVALUATION AND ACCOUNTABILITY

Accountability means assuming responsibility for one’s actions. Evaluation enhances nursing accountability by providing a mechanism for assisting the nurse to define, explain, and measure the results of nursing actions. Accountability is increased by ongoing evaluation; nurses are continually checking their own progress against predetermined standards.

Accountability is an integral part of professional nursing practice and is an important method through which commitment to quality client care can be demonstrated. “Nurses are accountable for designing effective care plans, implementing appropriate nursing actions, and judging the effectiveness of their nursing interventions” (Kenney, 1995, p. 195). In other words, nurses are accountable, for their judgments, decisions, and actions, to:

• Clients, families, and significant others

• Colleagues

• Employers

• The general public (society)

• The nursing profession

• Themselves.

MULTIDISCIPLINARY COLLABORATION IN EVALUATION

Evaluating the quality of care provided is a responsibility shared among members of the health care team. In addition to those directly involved (the health care providers, clients, and families), others interested in the outcomes of evaluation include the community and third-party payers (both public and private reimbursement organizations).

An ongoing monitoring process is implemented to evaluate quality of care. Ideally, every discipline monitors its own quality efforts. No single discipline is responsible for all-inclusive evaluation of client care. However, in most health care agencies, nurses are actively involved in monitoring evaluation activities. Many agencies have nurses on staff who function either as quality management coordinators, utilization review evaluators, or both.

When health care providers from all the relevant disciplines are involved in evaluation, the result is decreased fragmentation of care. The team approach mandates active involvement of all care providers in the evaluation of quality care. Multidisciplinary evaluation helps promote a continuum of care for the client, from the preadmission phase to discharge planning and follow-up care.

KEY CONCEPTS

• Evaluation, the fifth step in the nursing process, involves determining whether the client goals have been met, have been partially met, or have not been met.

• The purposes of evaluation are to determine the client’s progress or lack of progress toward achievement of client objectives, to judge the value of nursing actions in helping clients to achieve objectives, to determine the health care agency’s overall ability to deliver care in an effective and efficient manner, and to promote nursing accountability.

• Evaluation is based primarily on the skills of communication and observation.

• Evaluation is a mutual, ongoing process occurring among the nurse, client, family, and other health care providers.

• The effectiveness of nursing interventions is evaluated by examination of goals and expected outcomes that provide direction for the plan of care and serve as standards by which the client’s progress is measured.

• Evaluation is an orderly process consisting of seven steps: establishing standards; collecting data related to the goals and expected outcomes; determining goal achievement; relating nursing actions to client status; judging the value of nursing interventions in assisting clients to achieve goals and objectives; reassessing the client’s status; and modifying the plan of care if necessary.

• There is a relationship between quality management and evaluation. Evaluation is necessary in the provision of quality care because it is the mechanism used by nurses in determining how to improve care.

• Structure evaluation judges a health care agency’s ability to provide the services offered to its client population.

• Process evaluation measures nursing actions by examining each phase of the nursing process to determine the effectiveness of the actions in helping clients meet expected outcomes and goals.

• Outcome evaluation compares the client’s current status with the expected outcomes and examines all direct care activities that affect the client’s status.

• A nursing audit can focus on implementation of the nursing process, client outcomes, or both in order to evaluate the quality of care provided.

• Peer evaluation (peer review) is the process by which professionals provide to their peers performance appraisal feedback geared toward corrective action.

• Evaluation enhances professional nursing accountability by providing a mechanism for assisting the nurse to define, explain, and measure the results of nursing actions.

• Evaluating the quality of care is a shared responsibility among members of the health care team.

CRITICAL THINKING ACTIVITIES

1. When does evaluation of nursing care occur?

2. Describe the three types of evaluation and compare them in terms of purpose and methodology.

3. How does evaluation promote the individual nurse’s accountability?

4. State specific ways in which a nurse can perform process evaluation.

5. What are the advantages of peer evaluation?

6. Develop criteria for conducting a nursing audit related to client safety in an extended-care facility.

NURSING ASSESSMENT

Assessment is the first step in the nursing process and includes systematic collection, verification, organization, interpretation, and documentation of data for use by health care professionals. The accompanying display presents the essential elements of the assessment process. Effective planning of client care depends on a complete database and accurate interpretation of information. Incomplete or inadequate assessment may result in inaccurate conclusions and incorrect nursing interventions. Proper collection of assessment data directs decision-making activities of professional nurses.

The goal of assessment is the collection and analysis of data that are used in formulating nursing diagnoses, identifying outcomes and planning care, and developing nursing interventions. This chapter discusses the purpose of assessment, types of assessment, and the use of data in the assessment process.

PURPOSE OF ASSESSMENT

The purpose of assessment is to establish a database concerning a client’s physical, psychosocial, and emotional health in order to identify health promoting behaviors as well as actual and/or potential health problems. The American Nurses Association (ANA), in its Standards of Clinical Nursing Practice (1998), supports the use of the nursing process and outlines the essential components of assessment in this process (see the accompanying display). Through assessment, the nurse determines the client’s functional abilities and the absence or presence of dysfunction. The client’s normal routine for activities of daily living and lifestyle patterns are also assessed. Identification of the client’s strengths provides the nurse and other members of the treatment team information about the skills, abilities, and behaviors the client has available to promote the treatment and recovery process. Some examples of client strengths are family support, intelligence, spiritual beliefs, and coping skills (how previous problems have been solved). The assessment phase also offers an opportunity for the nurse to form a therapeutic interpersonal relationship with the client. During assessment, the client is provided an opportunity to discuss health care concerns and goals with the nurse.

TYPES OF ASSESSMENT

The type and scope of information needed for assessment are usually determined by the health care setting and needs of the client (see Figure 6-1).

Three types of assessment are comprehensive, focused, and ongoing. Although a comprehensive assessment is most desirable in initially determining a client’s need for nursing care, time limitations or special circumstances may dictate the need for abbreviated data collection, as represented by the focused assessment.

The assessment database can then be expanded after the initial focused assessment, and data should be updated through the ongoing assessment process.

COMPREHENSIVE ASSESSMENT

A comprehensive assessment is usually completed upon admission to a health care agency and includes a complete health history to determine current needs of the client. This database provides a baseline against which changes in the client’s health status can be measured and should include assessment of physical and psychosocial aspects of the client’s health, the client’s perception of health, the presence of health risk factors, and the client’s coping patterns.

FOCUSED ASSESSMENT

A focused assessment is an assessment that is limited in scope in order to focus on a particular need or health care problem or potential health care risks. Focused assessments are not as detailed as comprehensive assessments and are often used in health care agencies in which short stays are anticipated (e.g., outpatient surgery centers and emergency departments), in specialty areas such as labor and delivery, and in mental health settings or for purposes of screening for specific problems or risk factors (e.g., well-child clinics). See the accompanying display for sample questions used to assess a client experiencing labor.

ONGOING ASSESSMENT

Systematic follow-up is required when problems are identified during a comprehensive or focused assessment. An ongoing assessment is an assessment that includes systematic monitoring and observation related to specific problems. This type of assessment allows the nurse to broaden the database or to confirm the validity of the data obtained during the initial assessment. Ongoing assessment is particularly important when problems have been identified and a plan of care has been implemented to address these problems.

Systematic monitoring and observations allow the nurse to determine the response to nursing interventions and to identify any emerging problems.

The nurse delivering care to a client at home uses ongoing assessment. In the home, the nurse often has to direct the client to provide information relevant to the current problem, as the client may have a tendency to spend a lot of time telling stories of past medical problems and treatment, as opposed to providing information relevant to the situation at hand (Humphrey, 1994). Use of specific questions will be most helpful in eliciting specific information (see the accompanying display).

DATA COLLECTION

The nurse must possess strong cognitive, interpersonal, and technical skills in order to elicit appropriate information and make relevant observations during the data collection process. This process often begins prior to initial contact between the nurse and the client, primarily through the nurse’s review of biographical data and medical records. Upon meeting the client, the nurse continues data collection through interview, observation, and examination. A variety of sources and methods are used in compiling a comprehensive database.

TYPES OF DATA

Client data include information that the client communicates concerning perceptions of his or her own health status, as well as specific observations made by the nurse.

These two types of information are referred to as subjective and objective data.

Subjective data are data from the client’s point of view and include feelings, perceptions, and concerns. The data (also referred to as symptoms) are obtained through interviews with the client. They are called subjective because they rely on the feelings or opinions of the person experiencing them and cannot be readily observed by another.

Objective data are observable and measurable (quantitative) data that are obtained through observation, standard assessment techniques performed during the physical examination, and laboratory and diagnostic testing.

These data (also called signs) can be seen, heard, or felt by someone other than the person experiencing them. Assessments that are comprehensive and accurate include both subjective and objective data.

See Table 6-1 for examples of both types of data.

SOURCES OF DATA

A comprehensive database should include data from every possible source (see the accompanying display). The client should always be considered the primary source of information; however, other sources should not be overlooked.

The client’s family and significant others can also provide useful information, especially if the client is unable to verbalize or relate information. In addition, other health care professionals who have cared for the client may contribute valuable information. Medical records should also be reviewed, including the medical history and physical examination; results of laboratory and diagnostic tests and various health care professionals should also be consulted.

Pertinent literature should be investigated in order to pursue relevant information and plan appropriate nursing interventions. Written standards are valuable sources of data for comparison, for example, a standard table of infant growth to determine if an infant’s weight and height are within normal growth range. Another valuable source of data is knowledge about the client’s normal parameters of functioning. The nurse’s knowledge based on experience is another important source of data.

METHODS OF DATA COLLECTION

The nurse collects information through the following methods: observation, interview, health history, symptom analysis, physical examination, and laboratory and diagnostic data. These approaches require systematic use of assessment skills that are discussed below.

OBSERVATION

The nurse uses the skill of observation to carefully and attentively note the general appearance and behavior of the client. These observations occur whenever there is contact with the client and include factors such as client mood, interactions with others, physical and emotional responses, and any safety considerations.

Observation helps the nurse determine the client’s status, both physical and mental. By carefully watching the client, the nurse can detect nonverbal cues that indicate a variety of feelings, including presence of pain, anxiety, and anger. Observational skills are essential in detecting the early warning signs of physical changes (e.g., pallor and sweating).

INTERVIEW

An interview is a therapeutic interaction that has a specific purpose The purpose of the assessment interview is to collect information about the client’s health history and current status in order to make determinations about the client’s health needs. Effective interviewing depends on the nurse’s knowledge and ability to skillfully elicit information from the client using appropriate techniques of communication. Observation of nonverbal behavior during the interview is also essential to effective’s data collection.

INTERVIEW PREPARATION

The interview is more productive if the nurse has an opportunity to prepare for the interaction. Such preparation includes review of the client’s medical records, conversations with other health care team members (e.g., personnel in emergency departments or long-term care facilities), and research of the presenting medical diagnosis. This information can be useful in obtaining the client’s relevant history and formulating a current needs assessment.

INTERVIEW STAGES

Since the assessment interview often occurs at the beginning of a nurse-client relationship, it is helpful to begin the process with an orientation phase. During this period introductions are made, rapport is established, and roles are defined. The nurse interviews for a variety of reasons throughout the nurse-client relationship, including data collection, teaching, exploration of the client’s feelings or concerns, and provision of support.

The first few minutes of the nurse-client meeting may give an indication of the type of interviewing needed, so it is important that the nurse exhibit good listening skills as the relationship leads into the interview process.

There are three phases to an interview: introduction, working, and closure.

INTRODUCTION

The introduction stage of the interview establishes the goals for the interaction. The primary goal of the assessment interview is the collection of data about the client. In this phase of the interview, the purpose and use of the data collection should be discussed. For example, the nurse might state, “I need to ask you a few questions and talk to you for a few minutes about your health so that we can better plan your care.”

Adequate time and privacy should be allowed for the interview so that the client feels free to share any information that may be relevant. The nurse should also inform the client about the approximate duration of the interview.

The client is more likely to respond freely if the interview environment provides comfort and privacy and if rapport exists between the client and the nurse. The nurse should sit (if possible), establish eye contact with the client, and listen attentively. It is the nurse’s responsibility to note nonverbal messages that can indicate that the client is uncomfortable, tired, or preoccupied with other matters. If this situation occurs, it might be necessary to complete the interview at a later time.

For example, if the client is guarding an incision and verbalizing discomfort or is extremely anxious about an impending procedure, only essential data are collected and the comprehensive interview is postponed until immediate needs have been met.

WORKING

The working stage of the interview focuses on the details of data collection. The scope of the assessment interview depends on the type of assessment to be conducted (e.g., comprehensive or focused). The interview may be structured and formal (used in situations when a large amount of information needs to be obtained) or unstructured and informal (used in interactions that focus on a specific area of concern to the client). The nurse should be familiar with the specific assessment format used by the health care agency so that attentionn can be focused toward the client rather than the form itself. The interview generally begins with questions about biographical and other nonthreatening information.

The client’s reason for seeking health care is also addressed early in the working phase. The depth of the majority of questions that the nurse will ask the client depends on the data collection model used by the health care agency. Information is usually gathered from the general to the specific, with details about intimate or potentially embarrassing topics reserved until later in the interview.

The Nursing Checklist provides guidelines for interview preparation.

Techniques used during the interview will be determined by the setting and purpose of the interview. A comprehensive interview that seeks to identify problems and concerns is facilitated by open-ended questions, while an interview that focuses on specific details about a presenting problem will be facilitated by direct, closed questions. For example, an emergency setting would likely employ more direct, closed questions, while admission to a long-term care facility might require greater use of open-ended questions.

Closed questions are questions that can be answered briefly or with one-word responses. For example, the question “Have you been in the hospital before?” is a closed question that can easily be answered by a one-word response. Questions about the dates of and reasons for the hospitalizations are also closed questions that require brief answers.

Open-ended questions are questions that encourage the client to elaborate about a particular concern or problem. For example, the question “What led to your coming here today?” is open-ended and allows the client flexibility in response. Both closed and open-ended questions can be effective in collecting information.

CLOSURE

Closure is established in the introduction phase when approximate time parameters are set. As the interview session is concluding, the nurse should indicate this fact by stating that almost all the information needed has been obtained or that the time for the interview is almost over. This action allows the client an opportunity to present any other relevant information and it avoids surprises when the interview terminates.

During the closure phase, the nurse summarizes what was covered or accomplished during the interview and requests validation of perceptions with the client. If the nurse or the client feels that additional time is needed for further exploration of specific points discussed during this session, plans can be made for future interviews.

HEALTH HISTORY

A primary focus of the data collection interview is the health history. The health history is a review of the client’s functional health patterns prior to the current contact with a health care agency. While the medical history concentrates on symptoms and the progression of disease, the nursing health history focuses on the client’s functional health patterns, responses to changes in health status, and alterations in lifestyle. The health history is also used in developing the plan of care and formulating nursing interventions.

DEMOGRAPHIC INFORMATION

Personal data including name, address, date of birth, gender, religion, race/ethnic origin, occupation, and type of health plan/insurance should be included. This information may be useful in helping to foster understanding of a client’s perspective.

REASON FOR SEEKING HEALTH CARE

The client’s reason for seeking health care should be described in the client’s own words. For example, the statement “fell off four-foot ladder and landed on right shoulder; unable to move right arm” is the client’s actual report of the event that precipitated his or her need for health care. The client’s perspective is important because it explains what is significant about the event from the client’s point of view. It is also important to determine the time of the onset of symptoms as well as a complete symptom analysis.

PERCEPTION OF HEALTH STATUS

Perception of health status refers to the client’s opinion of his or her general health. It may be useful to ask clients to rate their health on a scale of 1 to 10 (with 10 being ideal and 1 being poor), together with the clients’ rationale for their rating score. For example, the nurse may record a statement such as the following to represent the client’s perception of health: “Rates health a 7 on a scale of 1 (poor) to 10 (ideal) because he must take medication regularly in order to maintain mobility, but the medication sometimes upsets his stomach.”

PREVIOUS ILLNESSES, HOSPITALIZATIONS, AND SURGERIES

The history and timing of any previous experiences with illness, surgery, or hospitalization are helpful in order to assess recurrent conditions and to anticipate responses to illness, since prior experiences often have an impact on current responses.

CLIENT/FAMILY MEDICAL HISTORY

The nurse needs to determine any family history of acute and chronic illnesses that tend to be familial. Health history forms will frequently include checklists of various illnesses that the nurse can use as the basis of the questions about this aspect. The client should be instructed that family history refers to blood relatives. It is also helpful to indicate who the relative is in relation to the client (e.g., mother, father, sister).

IMMUNIZATIONS/EXPOSURE TO COMMUNICABLE DISEASE

Any history of childhood or other communicable diseases should also be noted. In addition, a record of current immunizations should be obtained. This is particularly important with children; however, records of immunizations for tetanus, influenza, and hepatitis B can also be important for adults. If the client has traveled out of the country, the time frame should be indicated in order to determine incubation periods for relevant diseases. The client should also be asked about potential exposure to communicable diseases, such as tuberculosis, or to human immunodeficiency virus (HIV).

ALLERGIES

Any drug, food, or environmental allergies should be noted in the health history. In addition to the name of the allergen, the type of reaction to the substance should also be noted.

For example, a client may report that he or she developed a rash or became short of breath. This reaction should be recorded. Clients may report an “allergy” to a medication because they developed an upset stomach after ingesting it, which the nurse will recognize as a side effect that would not necessarily preclude administration of the drug in the future.

CURRENT MEDICATIONS

All medications currently taken, both prescription and over-the-counter, are to be recorded by name, frequency and dosage. Remind clients that this information should include medications such as birth control pills, laxatives, and nonprescription pain relief medications. Ask which, if any, herbal preparations the client uses. Patterns related to caffeine and alcohol intake and use of tobacco or recreational drugs should also be explored.

Use of alternative/complementary treatment methods, including herbals, is often not shared by health care consumers. Some clients fear rejection or ridicule when divulging such information with health care providers. The nurse uses a sensitive, nonjudgmental approach when assessing for the client’s use of all healing practices.

DEVELOPMENTAL LEVEL

Knowledge of developmental level is essential for considering appropriate norms of behavior and for appraising the achievement of relevant developmental tasks.

Any recognized theory of growth and development can be applied in order to determine if clients are functioning within the parameters expected for their age group.

For example, if the nurse uses Erikson’s stages of psychosocial development, validation of an adult client attaining the developmental task of generativity versus stagnation can be validated by the nurse’s statement, such as “client prefers to spend time with his family; very involved in children’s school activities.”

PSYCHOSOCIAL HISTORY

Psychosocial history refers to assessment of dimensions such as self-concept and self-esteem as well as usual sources of stress and the client’s ability to cope.

Sources of support for clients in crisis, such as family, significant others, religion, or support groups, should be explored.

SOCIOCULTURAL HISTORY

In exploring the client’s sociocultural history, it is important to inquire about the home environment, family situation, and client’s role in the family. For example, the client could be the parent of three children and the sole provider in a single-parent family.

The responsibilities of the client are important data through which the nurse can determine the impact of changes in health status and thus plan the most beneficial care for the client.

ACTIVITIES OF DAILY LIVING

The activities of daily living is a description of the client’s lifestyle and capacity for self-care and is useful both as baseline information and as a source of insight into usual health behaviors. This database should include the following areas:

Nutrition: Includes type of diet and foods eaten and fluids consumed regularly, food preparation, the size of portions, and the number of meals per day. Food preferences and dislikes, as well as the client’s need for assistance in food preparation or eating should also be determined.

Elimination: Includes both urinary and bowel elimination frequency and patterns. Any recent changes or problems in these patterns should be noted.

Rest/sleep: Includes the usual number of hours of sleep, number of hours of sleep needed to feel rested, sleep aids used, and the time within the day or night when sleep usually occurs. Any bedtime rituals (especially with children) should also be noted.

Activity/exercise: Includes types of exercise and patterns in a typical day or week. If assistance is needed with activities such as walking, standing, or meeting hygienic needs, this information should be noted.