Nursing Process : EVALUATION

BY : CATHERINE KUCKYT, RN

Evaluation is an ongoing process that enables the nurse to determine what progress the patient has made in meeting the goals for care. The outcome criteria provide measures for determining outcomes of care.

lease Note that the nurse is not evaluating nursing interventions. In assessing outcomes of care, determine whether goals have been met, partially met, or not met at all. If the goals have not been met it will be necessary to re-evaluate the plan.The plan may need to be altered , to do this you will need to do a new assessment.

Evaluation also provides data for Quality Assurance audits.
Measurement Criteria:(2)

1. Evaluation is systematic and ongoing.
2. The client's response to interventions is documented.
3. The effectiveness of interventions is evaluated in relation to outcomes.
4. Ongoing assessment data are used to revise diagnosis, outcomes, and the plan of care are documented according to nursing standards.
5. The client, significant others, and the health care providers are involved in the evaluation process, when appropriate.

NOTE: For the purpose of examples of Nursing Process , I will be using the following Case Study through out this report.
Case Study:
Client with Liver Disease - Cirrhosis

Mr.K is a 45 year old polish male. Married with three children. He is currently unemployed. He has worked in the service industry for his entire life. He has been socially drinking since he was 13 yrs. He has a family history of alcoholism and diabetes. He has been admitted to ICU on three previous occassions for liver disease.

Sample Nursing Care Plan Now includes Evaluation:

Nursing Diagnosis
Imbalance Nutrition:Less than Body Requirements related to anorexia, metabolic imbalance

Goals and Outcome Criteria
Adequate nutrition:Stable body weight, consumes meals

Implementation(Interventions)
Explain the need for adequate food intake. Small frequent meals. Arrange for dietician consult.Record daily weight.

Evaluation
June 10:Weight stable, No further nausea.Tolerating three small meals a day

Nursing Diagnosis
Activity Intolerance related to fatigue

Goals and Outcome Criteria
Improved activity tolerance:Performs actvities of daily living without excessive fatigue

Implementation(Interventions)
Schedule nursing care for rest periods. Elevate head of bead to facilitate breathing. Deep breathing and excercise extremeties.

Evaluation
June 10: Able to tolerate activities of daily living. Ambulates for 10 min.

Nursing Diagnosis
Risk for Impaired Skin Integrity related to edema, immobility, pruritis,hypoproteinemi

Goals and Outcome Criteria
Intact skin: No redness or breaks in skin.No scratching

Implementation(Interventions)
Gentle bathing with mild soap and warm water. Client's nails should be kept short. If itching severe ask Doc. for medications to relieve the discomfort. Administer medications as ordered.

Evaluation
June 10: Skin intact.2+ Edema of ankles.


Nursing Diagnosis
Ineffective Breathing Patterns related to ascites


Goals and Outcome Criteria
Effective breathing:Respiratory rate of 12-20 per minute without dyspnea.

Implementation(Interventions)
Elevate head of bed to relieve pressure of abdomen. Chair sitting may be more comfortable, with elevated feet .If allowed.

Evaluation
June 10: Respiration within normal limits

Nursing Diagnosis
Risk for Injury related to impaired coagulation

Goals and Outcome Criteria
Absence of bleeding: No blood in emesis or stool, vital signs consistent with patient norms

Implementation(Interventions)
Handle client gently to avoid trauma. Apply presure to injection sites. Note stool characteristics.

Evaluation
June 10: No new bruisng noted

Nursing Diagnosis
Disturbed Thought Processes related to elevated blood ammonia


Goals and Outcome Criteria
Normal cognitive functions: Mentally alert, oriented

Implementation(Interventions)
Monitor mental , cognitive and neurological statis. Provide basic information. Notify doc. if changes in statis. Health teaching for family members on dietary restrictions. Be alert for drug therapy adverse side effects ie:diarrhea, vitamin K deficiency and otoxicity.

Evaluation
June 10: Alert and orientated to person, time and place