The evaluation focuses on the effectiveness of nursing interventions by reviewing the expected results to determine if they were met within the indicated deadlines. By applying the fundamental principles of critical thinking, client-centered treatment approaches, goal-oriented tasks, evidence-based practice (EBP) recommendations, and nursing intuition, the nursing process works as a systematic guide to client-centered care with five subsequent steps. These are Evaluation, Diagnosis, Planning, Implementation and Evaluation (ADPIE). Evaluation is the first step and involves critical thinking and data collection skills; subjective and objective.
Subjective data involves verbal statements from the patient or caregiver. Objective data are tangible, measurable data, such as vital signs, intake and production, and height and weight. Evaluation is an ongoing process that occurs every time you have contact with a patient. Once you perform an intervention, you collect subjective and objective data from the patient, family, and health care team members.
It also reviews knowledge about the patient's current status, treatment, resources available for recovery, and expected outcomes. By consulting previous experiences caring for similar patients, you are in a better position to know how to evaluate your patient. You can anticipate what to evaluate. Apply critical thinking attitudes and standards to determine if care outcomes are achieved (fig.
If the results are met, the patient's overall goals are also met. Compare the behavior and responses of the patients you evaluated before performing nursing interventions with the behavior and responses that occur after administering nursing care. Critical thinking directs him to analyze the findings of the evaluation (fig. Has the patient's condition improved? Can the patient improve or are there physical factors preventing recovery? To what extent does this patient's motivation or willingness to adopt healthier behaviors influence responses to therapy?.
As the nurse obtains new information and evaluates the client's responses to care, he can further individualize the initial care plan. The planning phase is where objectives and outcomes that directly impact patient care are formulated according to evidence-based practice (EBP) guidelines. These interventions are classified into seven fields or classes of interventions according to the nursing intervention classification system. Once all of the nursing intervention actions have been carried out, the team now learns what works and what doesn't by evaluating what was done beforehand.
Verbal data requires the nurse's listening skills to assess difficulties such as difficulty, tone of voice, assertiveness, anxiety, difficulty finding the desired word, and flight of ideas. Typically, when the nurse meets a patient for the first time, the nurse is expected to evaluate to identify the patient's health problems, as well as their physiological, psychological, and emotional state, and to establish a database on the client's response to health problems or illness and the ability to manage health care needs. Members of the health care team who contribute to patient care also collect the results of the evaluation. If the goals remain unmet, nurses should evaluate the reasons why these goals are not being achieved and recommend revisions to the nursing care plan.
Implementation is the step that involves the action or doing and actually carrying out the nursing interventions described in the care plan. Formulating a nursing diagnosis through the use of clinical judgment helps plan and implement patient care. In fact, evaluative measures are the same as evaluation measures, but they are performed at the point of care when decisions are made about the patient's condition and progress. Care plans provide communication between nurses, their patients, and other healthcare providers to achieve health care outcomes.
An example of the interview is the nursing health history, which is part of the nursing admission evaluation. The primary objective of a discharge plan is to improve the client's quality of life by ensuring continuity of care along with the client's family or other health care workers who provide ongoing care. .
