Nursing Evaluation
Gail Ladwig, RN, MSN, CHTP
Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
2Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Evaluation
Step 5 of the Nursing Process
3Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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.
4Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Critical Thinking
Process information that is gathered while performing the steps of the nursing process
Decision making for and with the client
5Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing Process: Steps
Use the acronym ADPIE Assessment Diagnosis Planning Implementation Evaluation
6Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Step One
Assessment
7Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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
8Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Step Two
Nursing Diagnosis
9Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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)
10Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Step Three
Planning
11Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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
12Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Step Four
Implementation
13Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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
14Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Step Five
Evaluation
15Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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.
16Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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?
17Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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.
18Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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.
19Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Outcomes and Nursing Diagnosis
Nursing diagnosis: Activity Intolerance
20Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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.
21Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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?
22Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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?
23Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Evaluation of Outcomes
Example
24Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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.”
25Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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.
26Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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?
27Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Summary
You have now completed all the steps of the nursing process:
1. Assessment2. Diagnosis3. Planning4. Implementation5. Evaluation
28Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Congratulations
Using the steps of the nursing process and standardized nursing language, you have provided excellent holistic nursing care for your client.