Week 6 Evaluation Nursing Process PDF

Nursing Process: Evaluating Outcomes COURSE OUTCOME  Explain management of care concepts  Describe principles of safe, patient-centered, evidence-based nursing care to adults at the basic level, guided by the Caritas philosophy  Discuss critical thinking and clinical reason...

Nursing Process: Evaluating Outcomes COURSE OUTCOME  Explain management of care concepts  Describe principles of safe, patient-centered, evidence-based nursing care to adults at the basic level, guided by the Caritas philosophy  Discuss critical thinking and clinical reasoning to provide quality patient care. COMPETENCY  Describe elements of the nursing process.  Discuss critical thinking strategies used when making clinical judgments.  Discuss the use of critical thinking to prioritize basic elements of patient care when implementing the nursing process.  Concepts  Clinical Decision Making:  A process used to examine and determine the best actions to meet desired goals; requires anticipating, recognizing and organizing patient problems to respond with urgency and/or importance in a preferential order to avoid or minimize adverse changes in a patient’s condition.  Unit Outcomes  Nursing Process: Evaluation  Discuss the relationship between critical thinking and evaluation.  Explain how evaluation measures the success of achieving goals.  Describe how evaluation leads to discontinuation or revision of a plan of care.  Develop a nursing care plan including priorities of care, goals, selection of interventions and patient evaluations.  Nursing Process Evaluation  The final phase of the nursing process Evaluating Outcomes  After implementing the nursing care, the nurse EVALUATES the desired outcomes.  Patient and the health care professional determine the patient’s achievement of the goals  Was the plan of care effective?  Based on the response, plan is continued, modified, or terminated Evaluating Outcomes  Evaluation continues until the patient achieves the health goals or is discharged from the nurse’s care.  During and after implementation of nursing interventions  Evaluation can be done at specified intervals to review progress toward goals Example: Home care weekly evaluation Example: Discharge Critical Thinking: Evaluation  Evaluation of the patient is an ongoing process.  Critical thinking: Drawing conclusions, making judgement  Evaluate the data that indicates if the patient goals have been met  Can indicate that the interventions of the nurse were successful. Critical Thinking: Evaluation  Drawing conclusions: The nurse uses judgment about goal achievement and plan effectiveness  Met?  Unmet? More work to do. Interventions not working. Nursing plan of care needs to be modified. Let’s Practice: Evaluation  The nurse evaluates the patient’s response to the medication therapy to update the care plan. The nurse assesses the patient’s pain before administration of a Non-steroidal anti-inflammatory drug (NSAID) and then approximately 30 – 60 minutes after administration.  Know the baseline (before the medication)  Determine effectiveness 30 to 60 minutes after  Evaluation ongoing, with each administration  Evaluating Outcomes  Did the nursing care help the patient? Resolve actual health problems Prevent potential problems Maintain a healthy state Evaluating Outcomes How do we know how to evaluate?  Use measurable criterion-based evaluation (ANA and agency standards)  Collaborating with the patient and family  Using ongoing assessment data to revise the plan of care as needed  Achievement of goal (observable)  The physiological, emotional, and behavioral responses that are expected. (Part of your learning) Example: What the patient’s goal and expectations are? Getting back to previous lifestyle Example: Standards established Criterion- by an organization Based Standard ADA: all diabetics know signs/symptoms low BS s Criteria are the measurable and observable patient behaviors Evaluate after taking action  Determining a patient’s response to nursing care requires the use of evaluative measures, which require assessment skills and techniques. Goal/Outcomes Take action Evaluate outcomes Nursing Diagnosis Readiness for enhanced knowledge related to new diet parameters as evidenced by patient stating “I would like to order my own food.” Goal Patient will obtain knowledge Expected Outcomes or Criterion: The patient will: List 3 foods high in sodium. Taking Actions: The nurse discusses foods high in sodium with the patient and family and provides a written list of high sodium foods. Evaluating Outcomes: The patient has: Listed 3 foods high in sodium; Patient response: canned soup, potato chips, ham. Goal/Outcomes Take action Evaluate outcomes Expected Outcomes or Criterion:  The patient will:  Demonstrate dressing change to the right foot Taking Action: The nurse provides dressing supplies to the patient. The nurse demonstrates the dressing change Evaluating Outcomes:  The patient has not demonstrated dressing change to right foot.  Patient unable to open dressing packages due to severe arthritis in both hands. RN will revise plan of care; contact Social Worker for Home Health Referral for dressing change. Intent of the evaluation  DOES PROBLEM STILL EXIST? IMPROVING? ELIMINATED?  Does the patient still have the problem? (Unresolved)  Is the problem eliminated? (Resolved)  Some improvement (partially resolved) Collaborative Evaluation  Collaborate with the patient and family.  If your patient meets a goal successfully, discontinue that portion of the patient’s care plan. Documentation of the Nursing Process Has the goal been met?  All phases need to YES be documented Does the patient agree? YES  Progress needs to be documented Document the problem as Resolved and discontinue/stop the plan. Evaluation: Goal is Not Resolved The nurse will be able to adjust the plan of care if the goal is not resolved. Unresolved or partially resolved goals require you to continue addressing the patient’s problem. The nurse must Modify the plan of care.  Revising a Care Plan  Modifying a care plan:  Reassessment = Start Again  Re-diagnose = Start Again  Goals and expected outcomes = Review/Revise  Time Frame = Patient requires more time to reach the goal, set a future date for the patient to achieve the goal and evaluate at that time.  Review Interventions – revise or develop new  Registered Nurse CAN MODIFY ANY PART OF THE CARE PLAN Nursing Program: Plan of Care  The Care Plan documents the critical thinking and clinical judgement involved in the Nursing Process.  This semester you will have an opportunity to develop a Plan of Care for your patient.  We will have opportunities for practice! Nursing Process Worksheets NURS 1090 Finished the Nursing Process