Nursing Process: EVALUATION
Evaluation is an ongoing process that enables the nurse to determine what progress
the patient has made in meeting the goals for care. The outcome criteria
provide measures for determining outcomes of care.
Please Note that the nurse is not evaluating nursing interventions. In assessing outcomes of care, determine whether goals have been met, partially met, or not met at all. If the goals have not been met it will be necessary to re-evaluate the plan. The plan may need to be altered , to do this you will need to do a new assessment.
Evaluation also provides data for Quality Assurance audits.
Measurement Criteria:
- Evaluation is systematic and ongoing.
- The client's response to interventions is
documented.
- The effectiveness of interventions is evaluated
in relation to outcomes.
- Ongoing assessment data are used to revise
diagnosis, outcomes, and the plan of care are documented according to
nursing standards.
- The client, significant others, and the health
care providers are involved in the evaluation process, when appropriate.
NOTE: For the purpose of examples of Nursing Process , I will be using the
following Case Study through out this report.
Case Study:
Client with Liver Disease - Cirrhosis
Mr. K is a 45 year old polish male. Married with three children. He is currently unemployed. He has worked in the service industry for his entire life. He has been socially drinking since he was 13 yrs. He has a family history of alcoholism an diabetes. He has been admitted to ICU on three previous occasions for liver disease.
Sample Nursing Care Plan Now includes Evaluation:
|
Nursing Diagnosis |
Goals and
Outcome Criteria |
Implementation(Interventions) |
Evaluation |
|
Imbalance
Nutrition: Less than Body Requirements related to anorexia, metabolic
imbalance |
Adequate
nutrition: Stable body weight, consumes meals |
Explain the need
for adequate food intake. Small frequent meals. Arrange for dietician
consult. Record daily weight. |
June 10:Weight
stable, No further nausea. Tolerating three small meals a day |
|
Activity
Intolerance related to fatigue |
Improved
activity tolerance: Performs activities of daily living without excessive
fatigue |
Schedule
nursing care for rest periods. Elevate head of bead to facilitate breathing.
Deep breathing and exercise extremities. |
June 10: Able
to tolerate activities of daily living. Ambulates for 10 min. |
|
Risk for
Impaired Skin Integrity related to edema, immobility, pruritis,
hypoproteinemia |
Intact skin: No
redness or breaks in skin. No scratching |
Gentle bathing
with mild soap and warm water. Client's nails should be kept short. If
itching severe ask Doc. for medications to relieve the discomfort. Administer
medications as ordered. |
June 10: Skin
intact.2+ Edema of ankles. |
|
Ineffective
Breathing Patterns related to ascites |
Effective breathing:
Respiratory rate of 12-20 per minute without dyspnea. |
Elevate head of
bed to relieve pressure of abdomen. Chair sitting may be more comfortable,
with elevated feet .If allowed. |
June 10:
Respiration within normal limits |
|
Risk for Injury
related to impaired coagulation |
Absence of
bleeding: No blood in emesis or stool, vital signs consistent with patient
norms |
Handle client
gently to avoid trauma. Apply pressure to injection sites. Note stool
characteristics. |
June 10: No new
bruising noted |
|
Disturbed
Thought Processes related to elevated blood ammonia |
Normal
cognitive functions: Mentally alert, oriented |
Monitor mental
, cognitive and neurological statis. Provide basic information. Notify doc. if
changes in statis. Health teaching for family members on dietary
restrictions. Be alert for drug therapy adverse side effects i.e.: diarrhea,
vitamin K deficiency and otoxicity. |
June 10: Alert
and orientated to person, time and place |
Nursing Process: Definition |
Critical Thinking
| Guidelines
Critical Thinking:
Characteristics
| Skills, Elements, Standards
Nursing Process: Assessment
| Nursing Diagnosis
| Planning
| Implementation
| Evaluation
John
Philip Tiongco, MD