Open Resources for Nursing (Open RN) Show Evaluation is the sixth step of the nursing process (and the sixth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.”[1]Both the patient status and the effectiveness of the nursing care must be continuously evaluated and the care plan modified as needed.[2] Evaluation focuses on the effectiveness of the nursing interventions by reviewing the expected outcomes to determine if they were met by the time frames indicated. During the evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a patient’s expected outcomes have been met, partially met, or not met by the time frames established. If outcomes are not met or only partially met by the time frame indicated, the care plan should be revised. Reassessment should occur every time the nurse interacts with a patient, discusses the care plan with others on the interprofessional team, or reviews updated laboratory or diagnostic test results. Nursing care plans should be updated as higher priority goals emerge. The results of the evaluation must be documented in the patient’s medical record. Ideally, when the planned interventions are implemented, the patient will respond positively and the expected outcomes are achieved. However, when interventions do not assist in progressing the patient toward the expected outcomes, the nursing care plan must be revised to more effectively address the needs of the patient. These questions can be used as a guide when revising the nursing care plan:
Putting It TogetherRefer to Scenario C in the “Assessment” section of this chapter and Appendix C. The nurse evaluates the patient’s progress toward achieving the expected outcomes. For the nursing diagnosis Fluid Volume Excess, the nurse evaluated the four expected outcomes to determine if they were met during the time frames indicated:
Evaluation of the patient condition on Day 1 included the following data: “The patient reported decreased shortness of breath, and there were no longer crackles in the lower bases of the lungs. Weight decreased by 1 kg, but 2+ edema continued in ankles and calves.” Based on this data, the nurse evaluated the expected outcomes as “Partially Met” and revised the care plan with two new interventions:
For the second nursing diagnosis, Risk for Falls, the nurse evaluated the outcome criteria as “Met” based on the evaluation, “The patient verbalizes understanding and is appropriately calling for assistance when getting out of bed. No falls have occurred.” The nurse will continue to reassess the patient’s progress according to the care plan during hospitalization and make revisions to the care plan as needed. Evaluation of the care plan is documented in the patient’s medical record. 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 Diagnosis Outcomes / Planning Implementation Evaluation What is analysis in nursing process?Diagnosis/Analysis: The nurse identifies the actual and potential client problem(s) based on review and interpretation of the client data. Analyze Cues: The nurse reviews the relevant client data and determines what they mean.
Which action occurs during the planning stage of the nursing process?The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting.
Which action reflects a primary task in the analysis step of the nursing process?Which action reflects a primary task in the analysis step of the nursing process? Nurses form diagnostic conclusions according to identified problems that reflect patient conditions requiring nursing care in the analysis step of the nursing process.
What occurs during the assessment phase of the nursing process?Assessment involves collecting data via observation, physical examination, and interviewing. 4. This action reflects the evaluation step of the nursing process.
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