nursing evaluation gail ladwig, rn, msn, chtp mosby items and derived items © 2011 by mosby, inc.,...

Nursing Evaluation

Gail Ladwig, RN, MSN, CHTP

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Evaluation

Step 5 of the Nursing Process

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Definition: Nursing Process

The nursing process is an organizing framework for professional nursing practice.

The process is used in nursing to identify and treat the nursing diagnoses (problems) of a client.

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Critical Thinking

Process information that is gathered while performing the steps of the nursing process

Decision making for and with the client

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Nursing Process: Steps

Use the acronym ADPIE Assessment Diagnosis Planning Implementation Evaluation

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Step One

Assessment

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Definition: Assessment

Initial step of the nursing process Collection of information about the client Holistic and detailed Supports critical thinking Determines problems and strengths Ongoing during all phases of nursing process

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Step Two

Nursing Diagnosis

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Definition: Nursing Diagnosis

Clinical judgment Individual, family, or community Response to actual or potential health problems or

life processes Basis for outcomes and interventions The nurse is accountable

(North American Nursing Diagnosis Association-International, 2009-2011)

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Step Three

Planning

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Definition: Planning

Follows the nursing diagnosis This phase consists of writing measurable

client outcomes and nursing interventions to accomplish the outcomes

These outcomes and interventions are designed to change the client’s nursing diagnosis/problem

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Step Four

Implementation

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Definition: Implementation

Initiation of the nursing care plan Performing the nursing interventions Delegation of appropriate nursing

interventions Using skills

Psychomotor Interpersonal Cognitive

Performing continuous assessment

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Step Five

Evaluation

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Definition: Evaluation Although evaluation is listed as the last phase

of the nursing process, it is actually an integral part of each phase and something that is done continually.

Clients’ outcomes are evaluated to see if they were met.

If the outcomes were not met, then the nursing process is begun again, with assessment to determine the reason that the outcomes were not met.

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Evaluation: Critical Thinking Check the client outcomes. Were the outcomes met or not met? Is an additional assessment needed? Were the outcomes attainable? Was the correct nursing diagnosis selected? Does the nursing care plan need to be

modified?

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Evaluation: Critical Thinking (continued)

When using EBN, it is at this point that it is determined whether the practice that was followed was effective.

Necessary revisions may be made at this time.

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Sample: Case Scenario

A 73-year-old man has been admitted to the unit with an admitting medical diagnosis of COPD (chronic obstructive pulmonary disease). He states that he has “difficulty breathing when walking short distances” (RR = 26). He also states that his “heart feels like it is racing” (HR = 120) at the same time. He states that he is “tired all the time,” and while talking to you, he is continually wringing his hands and looking out the window.

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Outcomes and Nursing Diagnosis

Nursing diagnosis: Activity Intolerance

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Individualized Outcome

Activity tolerance improved As evidenced by (AEB):

Client will walk in hall three times a day for 5 minutes. Client’s heart rate (HR) will be >100 beats/min and

respiratory rate (RR) >20 breaths/min after activity. Client will state positive subjective feelings after

activity.

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Critical Thinking

Did the client walk in the hall three times a day for 5 minutes?

What were his HR and RR after activity? What statement did he make regarding the

activity?

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Critical Thinking (continued)

Compare the answers to these questions with the desired client outcomes.

Were the outcomes met? Are there any changes that need to be

made?

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Evaluation of Outcomes

Example

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Critical Thinking:Evaluation of Outcomes

Activity Intolerance improved AEB:

Client states, “I do not feel tired all the time anymore.”• HR was 90 beats/minute after walking in hall for 5

minutes Client states, “My heart isn’t racing anymore.”

• RR was 18 breaths/minute after walking in hall for 5 minutes

Client states, “My breathing is easier.”

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Critical Thinking

In this example, all of the client outcomes were met.

If they had not been met, then you would proceed to the first step of the nursing process and reassess the client.

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Reevaluate Ask:

Was more assessment information needed? Was the correct nursing diagnosis made? Were the outcomes correct? Were the outcomes relevant and realistic? Were the right interventions selected? Were the interventions based on EBN (evidence-

based nursing)? Were the interventions prioritized and timely?

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Summary

You have now completed all the steps of the nursing process:

1. Assessment2. Diagnosis3. Planning4. Implementation5. Evaluation

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Congratulations

Using the steps of the nursing process and standardized nursing language, you have provided excellent holistic nursing care for your client.