A nurse is evaluating a clients plan of care. the desired outcome of having the client sit

The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care.

Assessment
An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.

Diagnosis
The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse’s care plan.

Outcomes / Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.

Implementation
Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.

Evaluation
Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.

Notes

Introduction

• Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the nursing process, the client’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 effective. The nurse conducts evaluation measures to determine if expected outcomes are met, not the nursing interventions.
• The expected outcomes are the standards against which the nurse judges if goals have been met and thus if care is successful.Providing health care in a timely, competent, and cost-effective manner is complex and challenging. The evaluation process will determine the effectiveness of care, make necessary modifications, and to continuously ensure favorable client outcomes.

Definition

• Is assessment the client’s response to nursing interventions and then comparing that response to predetermined standards or outcome criteria.

Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals; in this phase nurse compare the client behavioral responses with predetermined client goals and outcome criteria. –CRAVEN 1996

Sample Case Study

Nursing Diagnosis : Impaired skin integrity related to physical mobility

Expected Outcomes : The patient will be able to get recovery of pressure sore.

Planning:

• Pressure sore dressing
  • Rationale: Cleansing the area will prevent further infection
• Back care
  • Rationale: It will promote blood circulation
• Change the position frequently
  • Rationale: It will put little pressure on the sore site
• Encourage the patient to ambulate
  • Rationale: It will put little pressure on the sore site
• Take protein rich diet
  • Rationale: Protein helps in repair of tissues

Evaluation : Wound healing was observed (tissues were red, healthy)

1. Determine client’s behavioral response to nursing interventions.
2. Compare the client’s response with predetermined outcome criteria.
3. Appraise the extent to which client’s goals were attained.
4. Assess the collaboration of client and health care team members.
5. Identify the errors in the plan of care.
6. Monitor the quality of nursing care.

Components of Evaluation

1. Collecting the data related to the desired outcomes
2. Comparing the data with outcomes
3. Relating nursing activities to outcomes
4. Drawing conclusion about problem status
5. Continuing, modifying, or terminating the nursing care plan

• The nurse collects the data so that conclusion can be drawn about whether goals have been met. It is usually necessary to collect both subjective & objective data. Data must be recorded concisely and accurately to facilitate the next part of the evaluating process.

•  If the first part of the evaluation process has been carried out effectively , it is relatively simple to determine whether a desired outcome has been met. Both the nurse and client play an active role in comparing the client’s actual responses with the desired outcomes.

• The third aspect of the evaluating process is determined whether the nursing activities had any relation to the outcome.

Drawing conclusion about problem status

• The nurse uses the judgement about goal achievement to determine whether the care plan was effective in resolving, reducing or preventing client problems. When goals have been met the nurse can draw one the following conclusions about the status of the client’s problem.
  • The actual problem stated in the nursing diagnosis has been resolved , or the potential problem is being prevented and the risk factors no longer exist. In these instances , the nurse documents that the goals have been met and discontinues the care for the problem.
  • The potential problem is being prevented, but the risk factors still present. In this case , the nurse keeps the problem on the care plan.
  • The actual problem still exists even though some goals are being met. In this case the nursing interventions must be continued.

After drawing conclusion about the status of the client’s problems , the nurse modifies the care plan as indicated. Whether or not goals were met, a number of decision need to be made about continuing, modifying or terminating nursing care for each problem.

Before making individual modification, the nurse must first determine why the plan as a whole was not completely effective. This require a review of the entire plan.

Factors Affecting Goal Attainment

1. Family Members
2. Health Team Members
3. Nurse

Evaluation Skill Required for Nurses

1. Nurse must know the hospital policies, procedure and protocols of interventions and recording.
2. Nurse must have up to date knowledge and information of many subject.
3. Nurse must have intellectual and technical skill to monitor the effectiveness of nursing interventions.
4. Nurse must have knowledge and skill of collecting subjective data and objective data.

Exam

Choose the letter of the correct answer. Good luck!

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When evaluating a clients plan of care the nurse determines that a desired outcome was not achieved which action should the nurse implement first?

What is the evaluation part of a nursing care plan?

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