Chapter 20: Evaluation Flashcards

1
Q

Evaluation: Two components

A
  1. examination of a condition or situation

2. judgement as to whether change has occurred (did the patient meet expected outcomes? was care successful?)

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2
Q

Once you deliver an intervention, you must:

A
  1. gather subj. & obj. data from pt, family & healthcare team members
  2. review knowledge regarding pts current condition, treatment, resources available for recovery, and expected outcomes
  3. refer to previous experience caring for similar patients - anticipate what to evaluate
  4. apply critical thinking attitudes & standards to determine if outcomes are achieved
  5. compare pt behavior and responses that you assessed before and after delivering nursing interventions.
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3
Q

Points to ponder

A
  • has pt’s condition improved?
  • is pt able to improve or are there physical factors preventing recovery?
  • to what degree does this pt’s motivation or willingness to pursue healthier behaviors influence responses to therapies?
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4
Q

Nurse Indicators to Evaluating Care include

A
  1. examine results according to clinical data collected
  2. compare achieved effect w/ goals and expected outcomes
  3. recognize errors or unmet outcomes
  4. understand pt situation participate in self-reflection, and correct errors
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5
Q

Care Plan Revisions

A
  1. discontinuing a care plan

2. modifying a care plan

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6
Q

Steps for Modifying a Care Plan

A
  • reassessment
  • redefining a diagnoses
  • reviewing expected goals and outcomes
  • review interventions for accuracy
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7
Q

Steps for Discontinuing or Modifying a Care Plan

A
  • evaluate in conjunction w/ the patient if goals have been met or not met and identify the factors that interfered with their achievement.
  • reassess the pt to determine accuracy of the nursing diagnosis.
  • establish new goals and expected outcomes and select new interventions.
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8
Q

At times, lack of goal achievement may result from

A

an error in nursing judgement or failure to follow each step of the nursing process

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9
Q

Modifying a Care Plan: Reassess

A
  • compare new data about the patient’s condition.

- using past experience helps direct the reassessment process.

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10
Q

Modifying a Care Plan: Redefine Diagnoses

A

as the pt condition changes, the diagnoses also changes.

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11
Q

Modifying a Care Plan: Goals and Expected Outcomes:

A
  • review the goals and expected outcomes for necessary changes.
  • clearly document the new goals and outcomes. All team members need to be aware.
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12
Q

Modifying a Care Plan: Interventions

A

Were they appropriate? Were the interventions applied correctly?

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13
Q

Interventions

A

adjusted according to the patient’s actual response to therapy and your previous experience with similar patients.

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14
Q

Appropriateness of interventions are based on

A

the standard of care for a patient’s health problem

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15
Q

Standard of Care

A
  • is the minimum level of care accepted to ensure high quality of care to patients
  • defines the types of therapies typically administered to patients with defined problems or needs.
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16
Q

Consulting with other nurses often yields

A

suggestions for improving the care delivery

17
Q

The American Nurses Association (ANA)

A

defines standards of professional nursing practice, which include standards for the evaluation step of the nursing process.

18
Q

Competencies for evaluation include:

A
  • Being systematic and using criterion-based evaluation
  • Collaboration with patients and other professionals
  • Using ongoing assessment data to revise the plan
  • Communicating results to patients and families
  • Ensure the responsible and appropriate use of interventions to minimize unwarranted or unwanted treatment
19
Q

The patient and/or family must

A

be actively involved in the evaluation process

20
Q

Proper evaluation

A

determines the effectiveness of nursing interventions.

21
Q

When doing an evaluation, the nurse should ask

A
  • what is the patient’s response to nursing care?
  • was the therapy effective in improving the patient’s physical or emotional health?
  • have the patient’s expectations been met?
22
Q

Evaluation measures

A
  • determine if the known problems have remained the same, improved, worsened or otherwise changed.
  • pt specific based on behavior, physical status and reaction to caregivers
23
Q

What is the patient’s first line of defense?

A

early detection of problems

24
Q

Evaluation of Outcomes

A

objectively evaluating the degree of success in achieving outcomes of care.

25
Q

Steps to Evaluating Outcomes of Care

A
  1. examine the outcome criteria to determine the exact desired pt behavior or response.
  2. evaluate the pt’s actual behavior or response.
  3. compare the established outcome criteria w/ the actual behavior or response.
  4. judge the degree of agreement between outcome criteria and actual behavior or response
  5. if no agreement, or partial agreement: What is/are the barriers? Why did they not agree?
26
Q

Documentation of Results

A

accurate info needs to be present in the pt’s medical record and shared during handoff communication.

27
Q

The use of standardized languages

A

improves the quality, consistency and accuracy of what is documented

28
Q

Federal and state regulations determine the standards for evaluation are to be

A

shared with patients and their families