NURSING PROCESS: Evaluation phase

Transcription

1 NURSING PROCESS: Evaluation phase Competencies Define the nursing process. Describe the finaluational step of the nursing process Explain the documentation of nursing process Apply the nursing process in case study 11-2 The Nursing Process for Foundation of Nursing Evaluation: the final step of the nursing process Stage 5 EVALUATION The last phase of the nursing process, follows implementation of the plan of care. Process., is a planned. ongoing,systematic Activity in which you will make judgements about: *the clients progress toward desired health outcomes. *the effectiveness of the nursing care plan. *the quality of nursing care in the helath care setting Why is evaluation essential to full spectrum nursing? *The patient is the nurses first priority. * It Helps nurses to conserver scarce resources. *Professional standards of practice The Ana code of ethics, The JCAHO and professional standards review organizations require evaluation. * It Helps ensure nursing survival * It Demonstrates caring and responsiblity. How are standards and criteria Used in evaluation? Criteria-Are measurable or observable characteristics, properties,attributing, or qualities. Reliable- If it yields consistent results--the same results every time, regardless of who uses it. Valid- It is really measured what it was intended to measure. Nursing Process 1

2 Types of Evalaution Evlaution is categorized according to: 1. what is being evaluated(structures, processes, or outcomes) 2. Frequency and time of evaluation Structure Evaluation Focuses on the setting in which care is provided. It explores the effect of orgnaizational characteristics on the qulatiy of care. Requires standards and data about plocies, procedures, fiscal resources, physical facilites and euqipments. Process evaluation Focuses on demonstrable(measurable changes) in the patient's health status that result from the care given. Terminal Evaluation Describes the cleints health status and prgress toward goals at the time of discharge. Ongoing evaluation While implementing, immediatel;y after an intervention or each patient contact Intermittent Evaluation Performed at specified times. It enables you to judge the progress toward goal acheivement and to modify the care plan as needed. How is Evaluation related to other steps of the nursing process? The patient outcomes stated in the planning outcomes stage must be concrete, observable and appropriate for the pt. in order to be useful as evaluation criteria. Evaluation overlaps greatly with the assessment step--both involve data collection. Evalution data are collected after intervention are perfromed to determine whether client goals were achieved. Process of Evaluating Client Responses Collecting data related to the desired outcomes Comparing the data with outcomes Relating nursing activities to outcomes Drawing conclusions about problem status Continuing, modifying, or terminating the nursing care plan. Nursing Process 2

3 Collect Reassessment data To minimize confusion, assessments made for the purpose of evaluation are caleld reasessment. Judge Goal achievement *acheived *Partially achieved *Not acheived When determining whether a goal has been achieved, the nurse can draw one of the three possible conclusions: The goal was met, that is the client response is the same as the desired outcomes. The goal was partially met, that is either a short term goal was achieved but the long term was not, or the desired outcome was only partially attained. The goal was not met. Relationship of Evaluation to Nursing Process When goals have been partially met or when goals have not been met, two conclusions may be drawn: The care plan may need to be revised, since the problem is only partially resolved OR The care plan does not need revision, because the client merely needs more time to achieve the previously established goals. So the nurse must reassess why the goals are not being partially achieved. Record the Evaluation Statement Professional standards require that you record your evaluation. Evaluation statements are written exactly the same as goals, but the scale number descrines the patients actual status. An evaluation statment should include: 1. The conclusion about whether the goal was achieved. 2. Reassessment data to support the judgement. How do I evaluate Collborative Problems? You will collect reassessment data the same as for nursing diagnoses. compare the reassessment data to established norms and dtermine whether data are within an acceptable range Nursing Process 3

4 Evaluate and Revising the Care plan *The clients ability and motivation to follow directions for treatment. *Avalaibility and support from family and significant others. *Treatments and therapies performed by other healthcare team members *Client fialure to provide complete information during assessment. Evaluate and Revising the Care plan (relate outcomes to interventions) (cont'd) *Clients lack of expereince, knowledge, or ability *Staffing in the instituiton (ration of licensed to unlicnesed caregivers: number of patients for whom a nurse is responsible) *Nurse's physical and mental well-being. Draw Conclusion about problem status Goals met: if all goals for a nursing diagnsoses have been met, you can discontinute the care plan for that diagnosis. Goals partially met: If some outcomes are met and others not, you may revise the care plan for that problem. Goals not met: If goals are not met, you should examine the entire plan and review all steps of the nursing process to decide whether to revise the care plan. Revise the Care Plan Review of assessment: review all initial and ongoing assessment data. Review of diagnosis Review of planning outcomes: if you had added data or revised it. Review of planning interventions: you will probably need to modify nursing orders Review of implementaion: It could be that goals were not met because of failure to implement the nursing orders or because of the manner in which it was implemented. examples of Evaluative Statements 1 Outcome/Goal Met. Pt ambulated from the bed to the chair X2 today. 2 Outcome/Goal Not met. Pt did not have a soft, formed stool today. 3 Outcome/Goal partially met. Pt verbalizes decreasing tobacco use from 3ppd to 2ppd DOCUMENTATION Nursing Process 4

5 Methods SOAPIER Subjective Objective Assessment Plan Implementation Evaluation Revision PIO Problem Intervention Outcome (continues) (continues) DAR Data Action Response PIE Problem Intervention Evaluation CBE Charting by exception Focus Specific to client s primary diagnosis (continues) Case Study Seorang klien datang dengan mengeluh kesakitan memegangi tangan kiri dan kaki kirinya. Klien mengatakan kalau ia kaget karena kompornya meledak setelah dia mengganti tabung gasnya. Klien terlihat meringis kesakitan dan matanya berair. Klien adalah pedagang baso keliling. Perawat memeriksa didapatkan luka bakar stadium 3 pada kaki dan tangan kirinya dengan kondisi luka mengelupas dan berwarna kekuningan. Tekanan darah 150/100 mmhg, nadi 105x/menit. Klien tidak bisa menggerakkan tangan & kaki kirinya. Nursing Process 5

6 Analisa Data Daftar Prioritas Diagnosa Kep. Data Etiologi Masalah Keperawatan Tanggal Proritas No Masalah Keperawatan Ttd Rencana Keperawatan Diagnosa Nomor... Nama Diagnosa Keperawatan...b.d... Tujuan :... Kriteria Hasil Implementasi Tgl Jam Dx Implementasi Respon Klien Ttd Indikator NIC: Progress Notes Evaluasi Diagnosa Keperawatan NOC NIC Indikator S S Diagnosa Keperawatan nomor... S : O : Indikator Skor awal Skor target Skor dicapai A : P : Nursing Process 6

7 exercise EVALUATION ACTIVITY Phase of the nursing process Mrs. Vernon is unconscious after a cerebral vascular accident (stroke). Presently she has no evidence of pressure ulcers but is at high for developing pressure ulcers. Which of the following goals is the most helpful to evaluate this nursing diagnosis? exercise (cont d) Will be turned at least every 2 hrs. Will be free of incontinence Will continue to demonstrate skin free of pressure ulcers ANY QUESTIONS? The Nursing Process for Foundation of Nursing K3LN>>>@Hany2008 Nursing Process 7