Nursing Process 19

8/17/2019 Nursing Process 19

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Melba Sahaya sweety D


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EVALUATION

Evaluation, the final step of the nursing process, is crucial to

determine whether, after application of the nursing process, theclient’s condition or well-being improves. The nurse applies

all that is known about a client and the client’s condition, as

well as experience with previous clients, to evaluate whether

nursing care was eective. The nurse conducts evaluation

measures to determine if e!pected outcomes are met, not the

nursing interventions. The expected outcomes are the standards

against which the nurse udges if goals have been met and thus

if care is successul.


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NURSING PROCESS

EVALUATION

"rs. #. $ot%i &op%ia' (rincipal'

#&I $A#ON' "adurai


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!roviding health care in a timel), competent, andcost-eective manner is comple! andc%allenging. The evaluation process willdetermine the effectiveness of care, makenecessary modifications, and to continuouslyensure avorable client outcomes. "valuation ofcare is a professional responsibility, and it is acrucial component of nursing care. "valuation canfocus on a single client’s plan of care, or it canfocus on the delivery of care provided by anagency or a specific nursing division within anagency. Through the continuous evaluation ofcare, nurses play a key role in the ongoingimprovement o client care.


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(U*(O&E& O+ EVALUATION

T%e purpose o evaluation' as described b) T%e OpenUniversit) (ublication,/01' are2

#. To determine whether the patient goals$expectedoutcomes have been achieved.

%. To measure the standards of nursing care.

&. To measure the 'uality of nursing care.

(. To discover which nursing actions are most consistentlyeffective in solving a particular patient problem.

). To measure staff performance.


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Evaluation also %elps to determine t%e eectiveness o t%e nursing

care plan 2

#. *hether the patient is making positive or negative progress.

%. *hether the patient is able to understand and participate in his care.

&. *hether changes have to be made in the care plan.

(. *hether new problems have been identified and new priorities have

to be set for care.

). *hether there is any change in the patient’s condition.

+. *hether there is a need to revise care plans.

. *hether the outcome of nursing care has been documented.


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3.-ollecting data todetermine whether

the criteria or

standards are met

4.nterpreting

and

summari/ing

findings

(.Documenting findings and

any clinical

udgment and

Evaluation process' includes ive elements 2

#.dentifying

evaluate

criteria 0

standards

5. Terminating,

continuing, or

revising the care

plan


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Identi)ing #riteria and &tandards

A nurse evaluates care b) 6nowing w%at to too6 or. 7it% clearl)

deined goals and e!pected outcomes t%e nurse %as ob8ective

criteria rom w%ic% to 8udge t%e client’s response to care.

9oals. A goal speciies t%e e!pected be%aviour or response t%at

indicates resolution o a %ealt%) state. It is a summar) statement

o w%at is to be accomplis%ed w%en all e!pected outcomes %avebeen met.


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#ollecting Evaluative "easures

Two aspects of care must be evaluated.

1irst, what is the client’s response to nursing care2

*as the therapy effective in improving the client’s physical or emotional

health2

Did the client benefit2Second, have the client’s expectations care been met2

T%e nurse as6s clients about t%eir perceptions o care' suc% as

:;id )ou receive t%e t)pe o pain relie )ou e!pected


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Interpreting and &ummari>ing +indings

"xpert nurses engage in an ongoing dialogue with a situation 34anner, 5ooper6kyriakidis, and stannard, #7778. They are able to read a clinical situationand then provide an appropriate response. 9n expert nurse recogni/esrelevant evidence, even evidence that sometimes does not match clinicalexpectations, and makes udgments about a client’s condition.

#. "xamine the goal statement to identify the exact desired client behavior orresponse

%. 9ssess the client for the presence of that behavior or response.

&. -ompare the established outcome criteria with the behavior or response

(. :udge the degree of agreement between outcome criteria and the behavior

or response.). f there is no agreement 3or only partial agreement 8 between the outcome

criteria and the behavior or response, what is$are the barriers2 *hy did theynot agree2.


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;ocumenting +indings

Accurate inormation must be present in a client’s

medical record in order for nurses to make

ongoing evaluation decisions. *hen documentingthe client’s response to interventions, the nurse

always includes the same evaluative measures

gathered during assessment.


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"odi)ing a #are plan

; *hen goals are not met, the nurse identifies the variables

or factors that interfere with goal achievement.


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I"(O*TANT #LUE& >

Evaluation is easier to perform after a nurse cares for a client over a long period.

Evaluation is enhanced by referring to previous experience and by asking

colleagues, familiar with the client, to confirm evaluation findings.

The accuracy of any evaluation improves when the nurse is familiar with the

client’s behavior and physiological status or has cared for more than one client

with a similar problem.

Evaluation of each expected outcome and its place in the se'uence of care isessential..

1ailure to evaluate each expected outcome results in an inability to determine

the place in which the se'uence faltered.


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Nursing ;iagnosis 2 ?isk for deficient fluid volume related to bleeding

9oals 2 5emodynamic status maintained@ urine output A &B mC$hr

NU*&IN9 INTE*VENTION& *ATIONALE E?(E#TE; OUT#O"E#. Avoid procedures@activities t%at can increase . (revents intracranial Level o consciousness ,LO#1intracranial pressure ,eg. coug%ing bleeding stable

&training to %ave a bowel "ovement1 #V( 5B3 cm C3O's)stolic D(

FG mm Cg

Urine output 4G mL@%our

3. "onitor vital signs closel)' 3. Identiies signs o ;ecreased bleeding

including neurologic c%ec6s2 %emorr%age@ s%oc6 ;ecreased oo>ing

"onitor %emod)namics Huic6l). ;ecreased ecc%)moses

"onitor abdominal girt% Amenorr%ea

"onitor urine output Absence o oral and

4. Avoid medications t%at 4. ;ecreases problems wit% bronc%ial bleeding

interere wit% platelet unction platelet aggregation Oral mucosa clean' moist'

i possible ,eg' A&A' N&AI;s' and ad%esion. intact.

beta-lactam antibiotics1

0. Avoid rectal probes' rectal 0. ;ecreases c%ance or

medications. *ectal bleeding.5. Avoid I" in8ections. 5. ;ecreases c%ance or

intramuscular bleeding.

T%e (atient 7it% ;isseminated Intravascular #oagulation ,;I#1


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Nursing ;iagnosis 2 *is6 or impaired s6in integrit) related to isc%emia or bleeding

9oals 2 &6in integrit) remains intact oral mucosa remains intact

NU*&IN9 INTE*VENTION& *ATIONAL E?(E#TE; OUT#O"E&

. Assess s6in' wit% particular . (rompt identiication o &6in integrit) remainsattention to bon) prominences' an) area at ris6 or s6in intact s6in is warm

s6in olds. Drea6down or s%owing and o normal color

earl) signs o brea6down

can acilitate prompt

intervention and t%usprevent complications.

3. *eposition careull) use 3-4 "eticulous s6in care Oral mucosa is intact pressure-reducing and use o measures pin6' moist' wit%out

mattress. to prevent pressure bleeding.

4. (erorm careul s6in care on bon) prominences

ever) 3 %r' emp%asi>ing decrease t%e ris6 o

dependent areas' all bon) s6in trauma.

prominences' perineum.

0. (erorm oral %)giene careull). 0. "eticulous care is needed

to decrease trauma' bleeding'

and ris6 o inection.

T%e (atient 7it% ;isseminated Intravascular #oagulation ,;I#1 ,continued1


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Nursing ;iagnosis 2 *is6 or impaired s6in integrit) related to isc%emia or bleeding

9oals 2 &6in integrit) remains intact oral mucosa remains intact

NU*&IN9 INTE*VENTION& *ATIONALE E?(E#TE; OUT#O"E&. Assess neurologic' pulmonar) . Initial signs o Arterial blood gases'O3 saturation'

integumentar) s)stems. t%rombosis can be pulse-o!imetr)' LO# wit%in

subtle. Normal limits.

3."onitor response to %eparin t%erap). 3. *esponse to %eparin Dreat% sounds clear

is most accuratel) Absence o edema

relected in Inta6e does not

ibrinogen level. E!ceed output4. Assess e!tent o bleeding 4. Ob8ective measure- 7eig%t stable

-ment o all sites o

bleeding are crucial

to accuratel) assess

e!tent o blood loss.

0. "onitor ibrinogen levels. 0. *esponse to %eparin is most

accuratel) relected in

ibrinogen level.

5. &top aminocaproic acid,EA#A1 5. EA#A s%ould be used onl) in

i s)mptoms o t%rombosis occur. setting o e!tensive %emorr%age

not responding to replacementt%erap).

T%e (atient 7it% ;isseminated Intravascular #oagulation ,;I#1 ,continued1


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Nursing ;iagnosis 2 Death anxiety

9oals 2 1ears verbali/ed$identified@ realistic hope maintained

NU*&IN9 INTE*VENTION& *ATIONALE E?(E#TE; OUT#O"E&#. Identi) previous coping . Identi)ing previous (reviousl) used coping

mec%anisms' i possible' stressul situations strategies identiied

encourage patient to can aid in recall o and tried' to e!tent

use t%em as appropriate. &uccessul coping patient is able to do so.

mec%anisms.

3. E!plain all procedures and 3. ;ecreased 6nowledge (atient indicates

rationale or t%ese in terms and uncertaint) can understanding o procedures

patient and amil) can increase an!iet). and situation as condition

understand. (ermit.

4. Assist amil) in supporting 4. +amil) can be useul patient. in assisting patient to

use coping strategies

and to maintain %ope.

0. Use services rom 0.Additional proessional

be%avioral medicine' intervention ma) be

c%aplain as needed. Necessar)' particularl)

i previous coping mec%anisms

are maladaptive or ineective.

&piritual dimensions s%ould be

supported.


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&6ills to be used b) Nurses to do eective Evaluation

,Je) #oncepts1

I. #ritical t%in6ing

II. Abilit) to compare and contrast

III. Abilit) to 8udge

IV. &6ill in documenting

V. (roblem solving abilit)


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NU*&IN9 (*O#E&& EVALUATION

. During evaluation the nurse applies #ritical t%in6ing to make clinical

decisions and redirect nursing care to best meet client needs.

. The nurse compares the client’s actual response 3e.g., behaviors and

physiological signs and symptoms8 to nursing interventions with

expected outcomes established during planning to determine if goals of

care are met.

. 9 nurse interprets evaluative findings to 8udge the client’s condition and

to know whether predicted changes have occurred.

IV. ;ocumentation of evaluative findings allows all members of the health

team to know whether a client is progressing or not.E. 9s a result of evaluation, a client’s nursing diagnoses, priorities, and

interventions may change.


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Nursing Process 19

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