Evaluation - Using the Nursing Process

EVALUATION

Evaluation, the final step of the nursing process, allows the nurse to determine the patient’s response to the nursing interventions and the extent to which the objectives have been achieved. The plan of nursing care is the basis for evaluation. The nursing diag-noses, collaborative problems, priorities, nursing interventions, and expected outcomes provide the specific guidelines that dic-tate the focus of the evaluation. Through evaluation, the nurse can answer the following questions:

·      Were the nursing diagnoses and collaborative problems accurate?

·      Did the patient achieve the expected outcomes within the critical time periods?

·      Have the patient’s nursing diagnoses been resolved?

·       Have the collaborative problems been resolved?

·       Have the patient’s nursing needs been met?

·       Should the nursing interventions be continued, revised, or discontinued?

·       Have new problems evolved for which nursing interven-tions have not been planned or implemented?

·      What factors influenced the achievement or lack of achieve-ment of the objectives?

·      Do priorities need to be reassigned?

·      Should changes be made in the expected outcomes and outcome criteria?

Objective data that provide answers to these questions are collected from all available sources (eg, patient, family, sig-nificant others, and health care team members). These data are included in the patient’s record and must be substantiated by direct observation of the patient before the outcomes are recorded.