In which stage of the nursing process does the nurse use client data to judge if the identified goal was met?
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Open Resources for Nursing (Open RN) Show
Evaluation is the sixth step of the nursing process (and the sixth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.”[1]Both the patient status and the effectiveness of the nursing care must be continuously evaluated and the care plan modified as needed.[2] Evaluation focuses on the effectiveness of the nursing interventions by reviewing the expected outcomes to determine if they were met by the time frames indicated. During the evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a patient’s expected outcomes have been met, partially met, or not met by the time frames established. If outcomes are not met or only partially met by the time frame indicated, the care plan should be revised. Reassessment should occur every time the nurse interacts with a patient, discusses the care plan with others on the interprofessional team, or reviews updated laboratory or diagnostic test results. Nursing care plans should be updated as higher priority goals emerge. The results of the evaluation must be documented in the patient’s medical record. Ideally, when the planned interventions are implemented, the patient will respond positively and the expected outcomes are achieved. However, when interventions do not assist in progressing the patient toward the expected outcomes, the nursing care plan must be revised to more effectively address the needs of the patient. These questions can be used as a guide when revising the nursing care plan:
Putting It TogetherRefer to Scenario C in the “Assessment” section of this chapter and Appendix C. The nurse evaluates the patient’s progress toward achieving the expected outcomes. For the nursing diagnosis Fluid Volume Excess, the nurse evaluated the four expected outcomes to determine if they were met during the time frames indicated:
Evaluation of the patient condition on Day 1 included the following data: “The patient reported decreased shortness of breath, and there were no longer crackles in the lower bases of the lungs. Weight decreased by 1 kg, but 2+ edema continued in ankles and calves.” Based on this data, the nurse evaluated the expected outcomes as “Partially Met” and revised the care plan with two new interventions:
For the second nursing diagnosis, Risk for Falls, the nurse evaluated the outcome criteria as “Met” based on the evaluation, “The patient verbalizes understanding and is appropriately calling for assistance when getting out of bed. No falls have occurred.” The nurse will continue to reassess the patient’s progress according to the care plan during hospitalization and make revisions to the care plan as needed. Evaluation of the care plan is documented in the patient’s medical record. Open Resources for Nursing (Open RN) Outcome Identification is the third step of the nursing process (and the third Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” The RN collaborates with the health care consumer, interprofessional team, and others to identify expected outcomes integrating the health care consumer’s culture, values, and ethical considerations. Expected outcomes are documented as measurable goals with a time frame for attainment.[1] An is a “measurable behavior demonstrated by the patient responsive to nursing interventions.”[2] Outcomes should be identified before nursing interventions are planned. After nursing interventions are implemented, the nurse will evaluate if the outcomes were met in the time frame indicated for that patient. Outcome identification includes setting short- and long-term goals and then creating specific expected outcome statements for each nursing diagnosis. Short-Term and Long-Term GoalsNursing care should always be individualized and patient-centered. No two people are the same, and neither should nursing care plans be the same for two people. Goals and outcomes should be tailored specifically to each patient’s needs, values, and cultural beliefs. Patients and family members should be included in the goal-setting process when feasible. Involving patients and family members promotes awareness of identified needs, ensures realistic goals, and motivates their participation in the treatment plan to achieve the mutually agreed upon goals and live life to the fullest with their current condition. The nursing care plan is a road map used to guide patient care so that all health care providers are moving toward the same patient goals. are broad statements of purpose that describe the overall aim of care. Goals can be short- or long-term. The time frame for short- and long-term goals is dependent on the setting in which the care is provided. For example, in a critical care area, a short-term goal might be set to be achieved within an 8-hour nursing shift, and a long-term goal might be in 24 hours. In contrast, in an outpatient setting, a short-term goal might be set to be achieved within one month and a long-term goal might be within six months. A nursing goal is the overall direction in which the patient must progress to improve the problem/nursing diagnosis and is often the opposite of the problem. Example. Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. had a priority nursing diagnosis of Fluid Volume Excess. A broad goal would be, “Ms. J. will achieve a state of fluid balance.” Expected OutcomesGoals are broad, general statements, but outcomes are specific and measurable. are statements of measurable action for the patient within a specific time frame that are responsive to nursing interventions. Nurses may create expected outcomes independently or refer to classification systems for assistance. Just as NANDA-I creates and revises standardized nursing diagnoses, a similar classification and standardization process exists for expected nursing outcomes. The Nursing Outcomes Classification (NOC) is a list of over 330 nursing outcomes designed to coordinate with established NANDA-I diagnoses.[3] Patient-CenteredOutcome statements are always patient-centered. They should be developed in collaboration with the patient and individualized to meet a patient’s unique needs, values, and cultural beliefs. They should start with the phrase “The patient will…” Outcome statements should be directed at resolving the defining characteristics for that nursing diagnosis. Additionally, the outcome must be something the patient is willing to cooperate in achieving. Outcome statements should contain five components easily remembered using the “SMART” mnemonic:[4]
See Figure 4.9[5] for an image of the SMART components of outcome statements. Each of these components is further described in the following subsections. SpecificOutcome statements should state precisely what is to be accomplished. See the following examples:
Additionally, only one action should be included in each expected outcome. See the following examples:
MeasurableMeasurable outcomes have numeric parameters or other concrete methods of judging whether the outcome was met. It is important to use objective data to measure outcomes. If terms like “acceptable” or “normal” are used in an outcome statement, it is difficult to determine whether the outcome is attained. Refer to Figure 4.10[6] for examples of verbs that are measurable and not measurable in outcome statements.  See the following examples:
Action-Oriented and AttainableOutcome statements should be written so that there is a clear action to be taken by the patient or significant others. This means that the outcome statement should include a verb. Refer to Figure 4.11[7] for examples of action verbs. See the following examples:
Realistic and RelevantRealistic outcomes consider the patient’s physical and mental condition; their cultural and spiritual values, beliefs, and preferences; and their socioeconomic status in terms of their ability to attain these outcomes. Consideration should be also given to disease processes and the effects of conditions such as pain and decreased mobility on the patient’s ability to reach expected outcomes. Other barriers to outcome attainment may be related to health literacy or lack of available resources. Outcomes should always be reevaluated and revised for attainability as needed. If an outcome is not attained, it is commonly because the original time frame was too ambitious or the outcome was not realistic for the patient. See the following examples:
Time LimitedOutcome statements should include a time frame for evaluation. The time frame depends on the intervention and the patient’s current condition. Some outcomes may need to be evaluated every shift, whereas other outcomes may be evaluated daily, weekly, or monthly. During the evaluation phase of the nursing process, the outcomes will be assessed according to the time frame specified for evaluation. If it has not been met, the nursing care plan should be revised. See the following examples:
Putting It TogetherIn Scenario C in Box 4.3, Ms. J.’s priority nursing diagnosis statement was Fluid Volume Excess related to excess fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.” An example of an expected outcome meeting SMART criteria for Ms. J. is, “The patient will have clear bilateral lung sounds within the next 24 hours.” During what stage of the nursing process does data collection occur?Nurses collect data during the assessment phase by communicating with the patient, spouse, and caregivers, reading patient records, nursing observation, and collecting measurable data such as vital signs.
In which step of the nursing process does the nurse analyze data and identify client problem?In which step of the nursing process does the nurse analyze data and identify client problems? In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. In the diagnosis phase, the nurse identifies the client's health status.
What are the 4 stages of the nursing process?The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care. Assessment. ... . Diagnosis. ... . Outcomes / Planning. ... . Implementation. ... . Evaluation.. In which step of the nursing process does the nurse validate and document data?The first phase of the nursing process is assessment. It involves collecting, organizing, validating, and documenting the clients' health status. This data can be obtained in a variety of ways.
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