The nurse may revise or discontinue unrealistic goals during which phase of the nursing process?

Question 1:

Evaluation is the fifth step of the nursing process that determines:

Whether a patient's condition or well-being improved after nursing interventions were delivered

Question 2:

Identify the four actions that show a nurse is competent to perform an evaluation

a. Examine the results of care according to clinical data collected

b. Compare achieved effects or outcomes with goal and expected outcomes

c. Recognize errors or omissions

d. Understand a patient situation, reflect on the situation, and correct the errors.

Question 3:

List the benefits of the Nursing Outcomes Classification (NOC)

a. Provide a means for nurses and other health care provers to evaluate the status of patients

b. Providing an outcomes measurement system

c. Offers a means to quantify the change in patient status after nursing interventions and to monitor patient progress

Question 4:

An outcome is:

A statement of progressive, step-by-step physical, emotional, or behavioral responses that a a patient needs to accomplish to achieve the goals of care

Question 5:

List the steps to evaluate the degree of success in achieving the outcomes of care

a. Examine the outcome criteria to identity the exact desired patient behavior

b. Assess the patient's actual behavior or response

c. Compare the established outcomes criteria with the actual behavior

d. Judge the degree of agreement between outcome criteria and the actual behavior

e. If there is no agreement between the outcome criteria and the actual behavior, what are the barriers?

Question 6:

Reflection-in-action involves

The nurse's ability to recognize how a patient is responding and then adjusting interventions as a result. The nurse may change the frequency of an intervention, change how the intervention is delivered, or select a new intervention based on the patient's response.

Question 7:

Briefly explain the following parts of the evaluative process:

Care Plan Revision

Each time the nurse evaluates a patient, he or she determines if the plan of care should continue, discontinue, or be revised

Question 8:

Briefly explain the following parts of the evaluative process:

Discontinuing a care plan

If the nurse and the patient agree that the expected outcomes and goals have been met, then that portion of the care plan is discontinued

Question 9:

Briefly explain the following parts of the evaluative process:

Modifying a care plan

Identify the factors that interfere with goal achievement

Question 10:

Briefly explain the following parts of the evaluative process:

Redefining the diagnosis

After reassessment, determine which nursing diagnosis is accurate for the situation and if the related factor or risk factor is accurate

Question 11:

Briefly explain the following parts of the evaluative process:

Revising goals and expected outcomes

Is each goal and expected outcome realistic for the problem, etiology, and time frame?

Question 12:

Briefly explain the following parts of the evaluative process:

Revising the Interventions

Examine the appropriateness of the intervention and the correct application of the intervention

Question 13:

Briefly explain the following parts of the evaluative process:

Documenting outcomes

Collaboration: Patient-centered care is only achieved when a patient and family are actively involved in the evaluation process

Question 14:

Identify the responsibilities of documenting and reporting

The nurse is responsible for consistent, thorough documentation of the patient's progress toward the expected outcomes and use of nursing diagnostic language. When documenting a patient's response to the interventions, the nurse should describe the intervention, the evaluative measured used, the outcomes achieved, and the continued plan of care.

Question 15:

Case Study

A patient has a pressure injury resulting from urinary incontinence and sustained pressure over the coccyx. The nursing care plan includes a goal of "pressure injury heals in 3 weeks." Identify some appropriate evaluative measures for this goal

Measure the diameter of the pressure injury, measure the depth of pressure injury

Question 16:

Measuring the patient's response to nursing interventions and his or her progress towards achieving goals occurs during which phase of the nursing process?

1. Planning
2. Evaluation
3. Assessment
4. Nursing Diagnosis

Rationale?

2. Determines whether the patient's condition or well-being has improved after the application of the nursing process

Question 17:

The criteria used to determine the effectiveness of a nursing action are based on the:

1. Nursing diagnosis
2. Expected outcomes
3. Patient's satisfaction
4. Nursing interventions

Rationale?

2. They are the expected favorable and measurable results of nursing care

Question 18:

When a patient-centered goal has not been met in the projected time frame, the most appropriate action by the nurse would be to:

1. Rewrite the plan using the different interventions
2. Continue with the same plan until the goal is met
3. Repeat the entire sequence of the nursing process to discover needed changes
4. Conclude that the goal was inappropriate or unrealistic and eliminate it from the plan

Rationale?

3. If the goals have not been met, you may need to adjust the plan of care by the use of interventions, modify or add nursing diagnoses with appropriate goals and expected outcomes, and redefine priorities.

Question 19:

Which of the following statements correctly describes the evaluation process? (Select all that apply)

1. Evaluation is an ongoing process
2. Evaluation usually reveals obvious change in a patient
3. Evaluation involves making clinical decisions
4. Evaluation requires the use of assessment skills
5. Evaluation is performed only when the patient's condition changes

Rationale?

1. Evaluation is an ongoing process

3. Evaluation involves making clinical decisions

4. Evaluation requires the use of assessment skills

What are the 4 stages of the nursing process?

In which situation would the nurse revise the nursing care plan?

What are the 5 phases components of nursing process?

What is the evaluation phase of the nursing process?