Assessment vs. Implementation
The Assessment VS Implementation strategy will assist you to establish priorities which involve the assessment and implementation steps of the nursing process. As a nursing student you have been drilled so that you can recite the steps of the nursing process in your sleep—assessment, analysis, planning, implementation, and evaluation. In nursing school, you did have some test questions about the nursing process, but you probably did not use the nursing process to assist you in selecting a correct answer on an exam. On the NCLEX-RN® exam, you will be given a clinical situation and asked to establish priorities. The possible answer choices will include both the correct assessment and implementation for this clinical situation. How do you choose the correct answer when both the correct assessment and implementation are given? Think about these two steps of the nursing process.
Assessment is the process of establishing a data profile about the client and his or her health problems. The nurse obtains subjective and objective data in a number of ways: talking to clients, observing clients and/or significant others, taking a health history, performing a physical examination, evaluating lab results, and collaborating with other members of the healthcare team.
Once you collect the data you compare it to the client’s baseline or normal values. On the NCLEX-RN® exam, the client’s baseline may not be given, but as a nursing student you have acquired a body of knowledge. On this exam you are expected to compare the client information you are given to the “normal” values learned from your nursing textbooks.
Assessment is the first step of the nursing process and takes priority over all other steps. It is essential that you complete the assessment phase of the nursing process before you implement nursing activities. This is a common mistake made by NCLEX-RN® exam takers: don’t implement before you assess. For example, when performing CPR, if you don’t access the airway before performing mouth to mouth resuscitation, your actions may be harmful!
Implementation is the care you provide to your clients. Implementation includes: assisting in the performance of activities of daily living (ADL); counseling and educating the client and the client’s family; giving care to clients; supervising and evaluating the work of other members of the health team. Nursing interventions may be independent, dependent, or interdependent. Independent interventions are within the scope of nursing practice, and do not require supervision by others. Instructing the client to turn, cough, and deep breathe after surgery is an example of an independent nursing intervention. Dependent interventions are based on the written orders of a physician. On the NCLEX-RN® exam, you should assume that you have an order for all dependent interventions that are included in the answer choices.
This may be a different way of thinking from the way you were taught in nursing school. Many students select an answer on a nursing school test (that is later counted wrong) because the intervention requires a physician’s order. Everyone walks away from the test review muttering “trick question.” It is important for you to remember that there are no trick questions on the NCLEX-RN® exam. You should base your answer on an understanding that you have a physician’s order for any nursing intervention described.
Interdependent interventions are shared with other members of the health team. For instance, nutrition education may be shared with the dietitian. Chest physiotherapy may be shared with a respiratory therapist.
Below are some examples of assessments and some inmplementations Remember that “action” does not always mean implementation!!! For example Make a thorough assessment of the circumstances is an assessment! It will give you data or information.
Examples of Implementations
Increase his consumption of foods containing simple sugars.
Increase his activity level
Hold his regular dose of insulin.
Document the results
Notify the physician that the client has become hypotensive
obtain an order to administer IV fluids
Place the client in semi-Fowler’s position
administer O2 at 4 liters
Administer a second dose of nitroglycerine
Instruct the client to cough and deep breathe.
Elevate the head of the bed.
Increase the rate of oxygen the client is receiving
Give his NPH insulin later in the evening
Continue with his medication regimen
Serve his bedtime snack earlier in the evening
Immobilize the affected limb with a splint and ask him not to move
Institute measures to minimize crying.
Perform postural drainage every two hours
Cough and deep breathe every hour
Give ice cream as tolerated
Stop the infusion.
Call the pharmacist
Attach the ties of the restraint to the bed frame
Perform range of motion to the restrained extremities once a shift.
Teaching the client about the importance of taking lithium as prescribed
Providing the client with a safe environment with few distractions
Setting limits on the client’s behavior
Turn the client on his left side
Change the suction from intermittent to continuous
Continue the irrigation
Administer the Lasix and Aldactone
Examples of assessments
Check his blood glucose level every 3–4 hours.
Check the pedal pulse and blanching sign in both legs.
Take Blood pressure and pulse
Check skin turgor
Ask family about health history of the patient
Check for breathlessness by placing an ear over the client’s mouth and observing the chest
Ask the client, “Are you choking?”
Determine that all the weights and ropes from the traction apparatus are in line and hanging free
Ask the client for more information about the location and characteristics of her pain
Check his blood sugar during the night
Check the Thomas splint and Pearson attachment to make sure they are appropriately positioned
Listen for bowel sounds
Take a pulse oximetry reading
Monitor the EKG for abnormal results
Observe the amount and characteristics of the returns
Obtain a clean catch urine specimen from a client suspected of having a urinary tract infection
Obtain a 24-hour diet recall from a client recently admitted with anorexia nervosa
Observe a client newly diagnosed with diabetes mellitus practice injection techniques using an orange
Check Serum electrolytes and digoxin level
Check WBC and RBC count
Have the test results repeated