Evaluation - RNpedia

Notes

🩺 Introduction to the Evaluation Phase of the Nursing Process

The Evaluation phase is the final—but far from least important—step in the nursing process. Think of it as the moment where the nurse “steps back” and critically reflects: Did the care we provided actually work? This phase ensures that all the hard work done during assessment, diagnosis, planning, and implementation is not just performed, but performed effectively—and with the patient’s best outcome in mind.

In simple terms, evaluation is the nurse’s quality control checkpoint. It helps identify which goals have been met, which ones need more time or adjustment, and which interventions may need to be changed or replaced altogether. This step empowers nurses to make evidence-based decisions, prevent complications, and provide safer, more effective care.

🧠 Why it matters: A nursing care plan is only as good as the results it produces. Evaluation lets nurses close the loop by comparing the patient’s actual outcomes with the expected outcomes set earlier. Without this step, the care plan becomes just a checklist—not a living, patient-centered strategy.

💡 Real-life example: Imagine you’ve been caring for a patient recovering from pneumonia. One of your goals was for the patient to maintain an oxygen saturation above 95% within 48 hours. After two days, you reassess—and the reading is 94%. It’s not quite the goal, so what now? That’s where evaluation kicks in—you analyze what worked, what didn’t, and what adjustments are needed.

🔍 What You’ll Learn in This Topic:

In the upcoming sections, we’ll explore how nurses:

Compare actual outcomes with expected goals
Judge the effectiveness of interventions
Decide to continue, modify, or terminate the plan of care
Document findings and communicate follow-ups
Collaborate with the healthcare team to ensure the best outcomes

🎯 Purpose of the Evaluation Stage

The evaluation stage of the nursing process is like the final scene of a movie—where everything comes together, and the outcome is revealed. In nursing, this is where you determine whether your nursing interventions actually helped your patient meet the goals you planned.

🩺 Why Do We Evaluate?

The main purposes of the evaluation stage are to:

Measure goal achievement: Did the patient meet the expected outcomes you set during the planning stage?
Assess intervention effectiveness: Were your nursing actions appropriate, timely, and helpful?
Decide what’s next: Should the care plan continue, be adjusted, or completely changed based on the patient’s progress?
Promote accountability: Evaluation helps ensure nurses provide evidence-based, results-driven care.
Improve patient outcomes: When nurses evaluate effectively, they’re more likely to detect issues early and prevent complications.

🧠 Relatable Example

Let’s say you had a goal for your post-operative patient: “Patient will report pain level of 3/10 or lower within 24 hours.”

After 24 hours, you assess their pain, and the patient reports 4/10.

❓Now what?
You evaluate: Did the pain meds help? Did the patient understand how and when to use them? Are they anxious or hesitant to report pain? This reflection guides your next move—adjusting the care plan, offering education, or consulting the provider.

🔄 Evaluation Isn’t Just an End—It’s a Feedback Loop

Think of evaluation as “continuous quality improvement.” It doesn’t just stop care—it shapes better care. If a goal was met, great—maybe now you set a new goal (e.g., preparing for discharge). If a goal was not met, it’s time to investigate why.

🧠 Memory Trick – Think “G.A.P.E.”

Use G.A.P.E. to remember the purposes of evaluation:

Goal Achievement check
Assess interventions
Plan continuation/modification
Enhance care quality

👉 “Nurses GAPE at the results to improve care!”

✏️ Student Mini Worksheet

Instructions: Match the following purposes with the correct descriptions.

A. Check if goals are met
B. Determine next nursing actions
C. Reflect on effectiveness of nursing care
D. Promote safe, evidence-based care

___ Evaluate how well interventions reduced a fever
___ See if patient walked 50 meters unassisted
___ Decide to continue or revise care plan
___ Ensure practice aligns with professional standards

Show Answer Key

📏 Establishing Evaluation Criteria and Standards

Before a nurse can evaluate anything, they need to know what exactly they’re evaluating against. This is where criteria and standards come in.

Criteria are the measurable patient responses or behaviors you’re looking for.
Standards are the acceptable levels of performance or expectations, often drawn from nursing guidelines, protocols, or evidence-based practice.

Together, they act like a grading rubric for patient care—letting you assess whether the goals have been met, how well they were met, and whether the plan needs to be continued or modified.

🧠 Example to Bring It to Life

Suppose your goal was:
“Patient will maintain blood glucose levels between 80–130 mg/dL within 48 hours.”

Your criterion is: blood glucose levels measured via glucometer
Your standard is: the range of 80–130 mg/dL, based on ADA guidelines

Now, when you check the patient’s glucose and find it’s consistently 140 mg/dL—you know the goal wasn’t met, and that guides your next steps.

🔍 Key Concepts:

Term	What It Means	Example
Criterion	A specific, measurable behavior or physiological finding	“Pain score below 3”
Standard	A benchmark or reference used to judge performance	“Vital signs within normal range per facility policy”

✅ In simple terms: Criteria are what you look for; Standards are what you compare it to.

🧠 Memory Trick – “C.R.I.T.”

To remember how to set evaluation criteria, think C.R.I.T.

Clear
Realistic
Individualized
Time-bound

👩‍⚕️ “Good criteria pass the CRIT test!”

📋 Clinical Practice Tip:

Use SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound) as your built-in criteria and standards. If your goals are SMART, your evaluation becomes naturally aligned.

✏️ Student Mini Worksheet

Directions: Identify whether each statement is a criterion, a standard, or both.

“Patient’s blood pressure is 118/76 mmHg.” → ______
“Maintain systolic BP < 130 per hospital protocol.” → ______
“Patient ambulated 50 feet without assistance.” → ______
“Pain goal: 2/10 or less within 1 hour after meds.” → ______

Show Answer Key

Criterion
Standard
Criterion
Both

📊 Collecting and Interpreting Patient Outcome Data

Once you’ve set clear criteria and standards, the next step is to gather the actual patient data that tells you how close (or far) the patient is to achieving the expected outcomes.

But collecting is only half the job. You must also interpret what that data means in the context of the patient’s progress and plan of care.

🔍 Step-by-Step Breakdown

1. Collect Data Systematically

Data collection should focus on the goals and outcomes set in the plan. You gather:

Objective data: Vital signs, lab values, wound measurements, intake/output
Subjective data: Patient statements like “I feel better” or “I’m still dizzy”

🧠 Example: If the goal is “Maintain temperature below 37.5°C,” then measuring the current temperature is key.

2. Use Multiple Sources

Patient (verbal reports)
Nurse observations
Electronic Health Records (EHR)
Diagnostic results
Input from interdisciplinary team (e.g., PT, dietitian)

3. Compare with Expected Outcomes

Ask:
✔️ Is the goal fully met?
➖ Partially met?
❌ Or not met at all?

4. Interpret the Meaning

What factors helped or hindered the outcome?
Are new problems arising?
Does the plan need to be changed or continued?

🧠 Real-Life Example

Goal: “Patient will report pain ≤ 3/10 within 1 hour after analgesic.”

Collected data: Pain now is 6/10 one hour after giving morphine.
Interpretation: Pain goal not met. You may need to reassess pain source, medication efficacy, or timing.

🧠 Memory Trick – Use D.A.T.A.

To remember how to work with patient outcome data, think:

Define expected outcomes
Assess current status
Take accurate measurements
Analyze results

📌 “When nurses handle DATA, they deliver quality care.”

💡 Pro Tip:

Always match the type of data to the type of goal:

Pain relief? → Ask the patient directly.
Infection control? → Look at WBC count and temperature trends.
Mobility? → Observe ambulation and balance.

✏️ Student Mini Worksheet

Directions: Read each patient scenario and decide if the outcome data suggests the goal is met, partially met, or not met.

Goal: “Patient will void at least 30 mL/hr.”
- Output: 35 mL/hr → _______
Goal: “BP will remain below 140/90.”
- BP: 142/92 → _______
Goal: “Incision site will remain free of redness and swelling.”
- Finding: Slight redness, no swelling → _______
Goal: “Patient will report no nausea.”
- Report: “Still feels slightly queasy” → _______

Show Answer Key

Met
Not Met
Partially Met
Partially Met

🎯 Determining Goal Achievement: Met, Partially Met, Unmet

Once patient outcome data is collected and interpreted, the nurse makes a clinical judgment:
Did the patient achieve the goal?
The outcome is categorized into three possible levels:

1. Goal Met

The patient has fully achieved the desired outcome within the time frame.

🧠 Example:
Goal: “Patient will ambulate 50 feet with a walker by Day 3.”
Finding: Patient ambulated 60 feet with no assistance on Day 2.
Conclusion: Goal met.

📌 What to do next: Discontinue that specific goal and document success. Set new goals if needed (e.g., “Ambulate 100 feet by discharge”).

2. Goal Partially Met

The patient made progress but did not fully meet the goal criteria.

🧠 Example:
Goal: “Patient will report pain ≤ 3/10 within 1 hour after analgesia.”
Finding: Pain decreased from 8/10 to 5/10.
Conclusion: Goal partially met.

📌 What to do next: Reassess the plan. Continue or modify the intervention (e.g., adjust medication timing, explore non-pharm pain relief).

❌ 3. Goal Not Met

The patient made no progress toward the goal, or the condition worsened.

🧠 Example:
Goal: “Patient will have no signs of wound infection by Day 5.”
Finding: Wound is red, warm, and has purulent discharge.
Conclusion: Goal not met.

📌 What to do next: Investigate contributing factors. Modify or replace the care plan. Collaborate with the healthcare team to reassess treatment.

🧠 Memory Trick – M.P.U. = Measure Patient’s Upshot

Met = Mission accomplished
Partially Met = Progress, but not perfection
Unmet = Uh-oh, something’s not working

📈 Think Like a Nurse: Ask Yourself

Is the outcome clearly documented and measurable?
Is the outcome time-specific and relevant to the goal?
Do I need to revise the intervention, goal, or both?

✏️ Student Mini Worksheet

Instructions: Read each scenario and choose the correct outcome classification.

Goal: “Patient will verbalize 3 coping strategies by discharge.”
- Patient shared 2 strategies. → _______
Goal: “Oxygen saturation will stay above 94% on room air.”
- Sat remained at 96%. → _______
Goal: “No new pressure injuries by Day 5.”
- New Stage 1 ulcer noted on sacrum. → _______
Goal: “Wound drainage will decrease by 50% in 3 days.”
- Drainage decreased by 25%. → _______

Show Answer Key

Partially Met
Met
Unmet
Partially Met

📝 Documenting and Reporting Evaluation Findings

After determining whether goals were met, partially met, or unmet, it’s time to record your findings and report them clearly. Without proper documentation, even excellent nursing care becomes invisible—and unsafe.

Think of this step as the nurse’s way of saying:

“Here’s what we planned, here’s what happened, and here’s what needs to happen next.”

📋 What Should Be Documented?

Your evaluation notes should include:

The goal/outcome that was being evaluated
Patient response or data collected
Level of goal achievement: Met, Partially Met, or Unmet
Any modifications needed to the care plan
Follow-up actions or recommendations

🧠 Example of a Good Evaluation Note:

Goal: “Patient will maintain SpO₂ > 95% on room air.”
Finding: “SpO₂ at 97% consistently for the past 24 hours.”
Evaluation: “Goal met. Continue current respiratory interventions. Monitor for recurrence of desaturation.”

💬 Reporting to the Team

Evaluation findings should be verbally communicated during:

Change-of-shift reports
Interdisciplinary rounds
Critical situation updates (e.g., worsening condition)

This ensures continuity of care, informed decision-making, and immediate attention to any emerging issues.

📌 Tips for Effective Documentation:

Use concise, objective language
Avoid vague phrases like “seems better”
Be specific: use measurable data and patient quotes when appropriate
Stick to factual observations, not assumptions
Use EHR templates or flowsheets as required by your facility

🧠 Memory Trick – Use “G.R.A.D.E.” when documenting evaluation:

Goal stated
Response described
Achievement level noted
Decision for plan continuation/modification
Evidence (data or patient statements)

👉 “Nurses assign a GRADE to care outcomes!”

✏️ Student Mini Worksheet

Directions: Identify what’s missing in each documentation entry.

“Patient says she feels better. Will continue current plan.” → What’s missing? __________
“Pain now 2/10. Pain goal was ≤ 3/10. Will maintain meds.” → What’s missing? __________
“Goal not met. Will notify provider.” → What’s missing? __________
“Blood glucose 110 mg/dL; goal 80–130. Goal met. Continue diet and meds.” → What’s missing? __________

Show Answer Key

Goal not clearly stated; vague data
Goal itself is missing
Patient data not described
Complete entry – nothing missing

🔄 Modifying the Plan of Care Based on Evaluation

Once evaluation reveals that a goal was partially met or unmet, the nurse must decide what changes are needed. Nursing care plans are not set in stone—they are dynamic and should evolve based on how the patient responds to care.

💡 This step is not a failure—it’s a fine-tuning process to get the patient closer to the best outcome.

🔍 When to Modify the Plan

You should revise the care plan when:

The goals are unrealistic or unclear
Interventions are ineffective or poorly timed
The patient develops new problems or complications
There is a lack of patient adherence due to discomfort, misunderstanding, or other barriers
The patient’s condition or preferences change

🧠 Example:

Original goal: “Patient will walk 100 feet with a walker by Day 2.”
Finding: Patient only managed 20 feet and experienced dizziness.

📝 Modified Plan:

New goal: “Patient will walk 30 feet by Day 2 and sit upright for 10 minutes.”
Revised interventions: Add rest periods, consult PT, reassess for orthostatic hypotension.

🔁 What Can Be Modified?

Plan Component	How It Might Change
Goals	Make them more realistic, SMARTer, or extend the time frame
Interventions	Adjust the type, frequency, or intensity
Nursing Diagnosis	Add, remove, or reprioritize based on new findings
Expected Outcomes	Shift focus depending on evolving priorities

💡 Memory Trick – “R.E.N.E.W.” your Plan

When you need to update care, remember:

Review goals
Evaluate barriers
New data = new direction
Engage the patient
Write new interventions

📌 “Good nurses don’t restart—they RENEW the care plan.”

🧠 Quick Clinical Scenario:

Original Plan: Pain management with oral acetaminophen
Outcome: Pain score remains high
Modified Plan: Switch to IV NSAID, schedule rather than PRN, teach non-pharm methods like guided breathing

✏️ Student Mini Worksheet

Instructions: Read each evaluation result and decide which part of the care plan needs modification.

Outcome: “BP remains 160/100 after 3 days of walking and low-sodium diet.”
→ Modify: _______________
Outcome: “Patient reports confusion about home insulin injection.”
→ Modify: _______________
Outcome: “Goal: Pain <4/10. Patient reports 3/10. Goal met.”
→ Modify: _______________
Outcome: “Patient developed new pressure injury.”
→ Modify: _______________

Show Answer Key

Intervention – may need medication added
Patient education intervention
No modification needed
Nursing diagnosis and interventions

🧠 Memory Trick Recap: Key Mnemonics to Remember

Section	Memory Trick	Meaning
Purpose of Evaluation	G.A.P.E.	Goal Achievement, Assess Interventions, Plan Continuation, Enhance Quality
Criteria & Standards	C.R.I.T.	Clear, Realistic, Individualized, Time-bound
Outcome Data	D.A.T.A.	Define outcomes, Assess status, Take measurements, Analyze results
Goal Achievement	M.P.U.	Met, Partially Met, Unmet
Documentation	G.R.A.D.E.	Goal, Response, Achievement, Decision, Evidence
Modifying Plan	R.E.N.E.W.	Review, Evaluate barriers, New data, Engage patient, Write new plan

📋 All-in-One Interactive Worksheet: Evaluation Practice

Instructions: Read each item and answer the questions or select the correct option.

1. Identify the purpose of the Evaluation Phase:
a. To diagnose new conditions
b. To measure the effectiveness of nursing care
c. To discharge the patient
d. To administer medications
✅ Answer: ___

2. Which of the following is a standard, not a criterion?
a. “Pain rating of 2/10”
b. “SpO₂ ≥ 95%”
c. “Patient states, ‘I feel better’”
d. “Patient ambulated 40 feet”
✅ Answer: ___

3. What’s the best description of a partially met goal?
a. The patient’s goal was not achieved at all
b. The goal was completely achieved
c. Some improvement was observed, but not the full goal
d. New goals were created
✅ Answer: ___

4. Fill in the blank: Use the acronym _____ to guide your documentation of evaluation findings.
✅ Answer: ___________

5. True or False: If a goal is not met, the care plan must always be completely rewritten.
✅ Answer: ___________

6. Match the following outcomes with their evaluation status (Met, Partially Met, Not Met):

a. Pain decreased from 9/10 to 6/10 → __________
b. BP stayed < 140/90 as planned → __________
c. New fever and tachycardia appeared → __________

Show Answer Key

b
b
c
G.R.A.D.E.
False
a → Partially Met, b → Met, c → Not Met

💡 FAQs: Evaluation Phase (Based on Common Student Searches)

Q1: Do you document even if goals are met?
👉 Yes! Always document goal status—met, partially met, or not met—to provide legal and clinical evidence of care.

Q2: Can a partially met goal still mean patient progress?
👉 Absolutely. It reflects improvement but signals the need to adjust interventions or allow more time.

Q3: What if a patient refuses care—how is that evaluated?
👉 Evaluate the reasons (e.g., fear, cultural beliefs), document it, and revise the plan to include patient education or negotiation.

Q4: Who should the nurse report evaluation results to?
👉 To the healthcare team—especially during shift change, interdisciplinary rounds, or when outcomes require provider notification.

Q5: Is modifying the plan considered starting over?
👉 No. It’s a refinement. Evaluation makes the care plan smarter, not redundant.

📚 Suggested References

Potter & Perry’s Fundamentals of Nursing (10th ed.)
NANDA-I Nursing Diagnoses: Definitions and Classification
Carpenito’s Handbook of Nursing Diagnosis
ATI & Saunders NCLEX Review Books
Nursing and Midwifery Council Guidelines (NMC)

Exam

Welcome to your Evaluation Practice Exam! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.

✔ Exam Details

Number of Questions: 10 items
Mode: Practice Mode

✔ Exam Instructions

Practice Mode: This mode aims to facilitate effective learning and review.
Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

✔ Tips For Success

Read each question carefully. Take your time and don't rush.
Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
Take breaks if you need them. It's not a race, and your understanding is what's most important.
Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!

Click 'Start Exam' when you're ready to begin. Best of luck!

💡 Hint

Think about the foundational step a nurse must take to ensure that the care adjustments are accurately aligned with the client's current health status.

1 / 10

1. Nurse Cooper is adapting the care plan for a client whose health status has undergone considerable changes over the past few days. What is the most appropriate initial action for her to ensure the care plan meets the client's current needs?

A. Conduct a comprehensive reassessment of the client's condition and factors.

B. Modify only the nursing diagnoses and goals in the existing care plan.

C. Incorporate additional nursing interventions from a standard care plan.

D. Formulate a completely new care plan from scratch.

EXPLANATION

✔Correct answer:

Conduct a comprehensive reassessment of the client's condition and factors. The most appropriate initial action for Nurse Cooper is to conduct a comprehensive reassessment of the client's condition and factors. A thorough reassessment is crucial to accurately determine the client's current health status, identify any new or changed conditions, and understand the overall context affecting their health. This reassessment will provide the necessary information to update the care plan effectively, ensuring it addresses the client's current needs and provides the best possible care.

Think of this process like a mechanic reassessing a car that has developed new issues after initial repairs. The mechanic needs to re-evaluate the entire car to understand the current problems and determine the best course of action, rather than just fixing the specific parts that were initially problematic.

The nursing process is cyclical and dynamic, involving ongoing assessment, diagnosis, planning, implementation, and evaluation. A comprehensive reassessment aligns with the principles of patient-centered care and evidence-based practice, ensuring that the care plan is tailored to the client's evolving needs. This approach helps to identify any new issues, re-evaluate existing problems, and adjust interventions and goals to optimize patient outcomes.

✘Incorrect answer options:

Incorporate additional nursing interventions from a standard care plan. While additional interventions might be useful, they should be based on an updated assessment of the client's condition. Adding interventions without a comprehensive reassessment may not address the client's specific needs.

Formulate a completely new care plan from scratch. Formulating a new care plan might be necessary, but it should be based on a comprehensive reassessment. Starting from scratch without reassessment might overlook critical current information and context.

Modify only the nursing diagnoses and goals in the existing care plan. Modifying only the diagnoses and goals without a comprehensive reassessment may not fully address the client's current health status and needs, potentially leading to an incomplete or ineffective care plan.

References

Ackley, B. J., Ladwig, G. B., & Makic, M. B. (2017). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (11th ed.). Elsevier.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse's Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales (15th ed.). F.A. Davis Company.

💡 Hint

Focus on the assessment that directly relates to monitoring a key parameter affected by digoxin.

2 / 10

2. Nurse Harris has set a goal for her patient who is receiving digoxin therapy: "The patient will independently perform necessary assessments before taking their medication." Which capability should Nurse Harris evaluate to determine if the patient has met this outcome criterion?

A. Review their dietary habits.

B. Measure their respiratory rate.

C. Inspect their skin color.

D. Check their radial pulse.

EXPLANATION

✔Correct answer:

Check their radial pulse. The capability Nurse Harris should evaluate to determine if the patient has met the outcome criterion is checking their radial pulse. Patients on digoxin therapy must monitor their pulse rate before taking the medication because digoxin can affect heart rate and rhythm. It is crucial for the patient to check their pulse and ensure it is within a safe range (typically, digoxin should not be taken if the pulse is below 60 beats per minute) to avoid potential toxicity and adverse effects.

Think of it like a driver checking the fuel gauge before starting a long trip. Just as it's essential to ensure there's enough fuel to avoid running out, it's crucial for the patient to check their pulse to ensure their heart rate is safe for taking digoxin.

Monitoring the radial pulse is a specific, actionable, and critical assessment for patients on digoxin therapy. This practice helps prevent complications such as bradycardia (a dangerously slow heart rate), ensuring the medication is taken safely. Educating and evaluating the patient’s ability to perform this assessment independently supports self-management, enhances safety, and promotes optimal health outcomes.

✘Incorrect answer options:

Review their dietary habits. While diet can impact overall health and medication effectiveness, it is not directly related to the immediate safety assessment required before taking digoxin.

Inspect their skin color. Skin color inspection is not typically relevant to digoxin therapy management. It does not provide the necessary information about the patient's heart rate or potential digoxin toxicity.

Measure their respiratory rate. Although important for overall health assessment, respiratory rate measurement is not the primary focus for patients on digoxin. Monitoring the pulse rate is directly related to the medication's effects on heart function.

References

Lehne, R. A. (2019). Pharmacology for Nursing Care (10th ed.). Elsevier.
Lilley, L. L., Collins, S. R., & Snyder, J. S. (2020). Pharmacology and the Nursing Process (9th ed.). Elsevier.

💡 Hint

Consider the outcome that directly relates to a nurse's intervention and has a measurable impact on patient safety and care quality.

3 / 10

3. Nurse Alvarez is reviewing outcomes to determine which best represents a nurse-sensitive client outcome. Which of the following should she identify?

A. Clients will maintain daily personal hygiene.

B. Clients will express decreased anxiety about surgery.

C. Clients will have no falls during their hospital stay.

D. Clients will eat 75% of their meals.

EXPLANATION

✔Correct answer:

Clients will have no falls during their hospital stay. The best representation of a nurse-sensitive client outcome is "Clients will have no falls during their hospital stay." Nurse-sensitive outcomes are those that are directly influenced by nursing interventions and care. Preventing falls is a key indicator of the quality of nursing care and involves numerous nursing actions, such as assessing fall risk, implementing safety protocols, and providing patient education.

Think of this goal like a lifeguard ensuring no one drowns at a pool. The lifeguard's active monitoring, safety measures, and interventions directly prevent incidents, similar to how nursing care prevents falls.

Nurse-sensitive outcomes reflect the effectiveness and quality of nursing care. They are measurable and directly related to nursing activities, which can influence patient outcomes positively. By focusing on preventing falls, nurses can demonstrate their critical role in maintaining patient safety and promoting a healing environment.

✘Incorrect answer options:

Clients will maintain daily personal hygiene. While important, this outcome is not as strongly nurse-sensitive as preventing falls, since personal hygiene can also depend on the client's personal habits and preferences.

Clients will express decreased anxiety about surgery. Although reducing anxiety is a valuable nursing goal, it is influenced by multiple factors, including the client's psychological state and support system, and may not be directly measurable.

Clients will eat 75% of their meals. While nutrition is crucial, eating habits can be influenced by various factors beyond nursing care, such as the client’s appetite, preferences, and medical condition.

References

Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2018). Nursing Outcomes Classification (NOC): Measurement of Health Outcomes (6th ed.). Elsevier.
American Nurses Association. (2015). Nursing: Scope and Standards of Practice (3rd ed.). Silver Spring, MD: American Nurses Association.

💡 Hint

Consider which option directly relates to assessing the impact of all nursing actions on the patient's health outcomes.

4 / 10

4. The core objective of the nursing evaluation process is to:

A. Evaluate the overall success of the nursing care delivered.

B. Assess the nurse's capability in applying suitable nursing interventions.

C. Monitor the client's progress toward overall health and wellness.

D. Recognize which interventions are not effectively meeting client goals.

EXPLANATION

✔Correct answer:

Evaluate the overall success of the nursing care delivered. The core objective of the nursing evaluation process is to evaluate the overall success of the nursing care delivered. This involves assessing whether the goals set during the planning phase have been achieved and determining the effectiveness of the nursing interventions implemented. Evaluation allows nurses to identify successful outcomes, recognize areas needing improvement, and adjust the care plan accordingly to better meet the client's needs. This process ensures that nursing care is continuously optimized to promote the best possible health outcomes for the client.

Think of the nursing evaluation process like a coach reviewing a game plan after a match. The coach looks at what strategies worked, what didn’t, and how the team performed overall to improve future games. Similarly, the nursing evaluation reviews the care plan's success to enhance future patient care.

The nursing evaluation process is a critical component of the nursing process, which includes assessment, diagnosis, planning, implementation, and evaluation. It ensures that nursing care is patient-centered, evidence-based, and adaptive to the client's evolving health status. By evaluating the overall success of nursing care, nurses can ensure that interventions are effective and make necessary adjustments to enhance patient outcomes.

✘Incorrect answer options:

Monitor the client's progress toward overall health and wellness. While monitoring progress is an important part of evaluation, the core objective is broader and focuses on the overall success of the nursing care delivered.

Recognize which interventions are not effectively meeting client goals. Identifying ineffective interventions is a component of the evaluation process, but it is not the primary objective. The main goal is to assess the overall success of the nursing care.

Assess the nurse's capability in applying suitable nursing interventions. While evaluating nursing competencies is important, the primary focus of the evaluation process is on the outcomes of the nursing care provided to the client.

References

Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. (2020). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier.
Carpenito, L. J. (2016). Handbook of Nursing Diagnosis (15th ed.). Wolters Kluwer.

💡 Hint

Consider which method directly assesses the improvement in skin redness specified in the outcome.

5 / 10

5. Nurse Mitchell has established a specific outcome for a patient with a skin impairment: "Erythema will decrease within three days." To evaluate the effectiveness of the interventions, what should Nurse Mitchell focus on?

A. Choosing the right wound care products and techniques.

B. Recording the odor and color of any drainage from the area.

C. Inspecting the color and condition of the affected area.

D. Daily measuring of the ulcer's diameter.

EXPLANATION

✔Correct answer:

Inspecting the color and condition of the affected area. To evaluate the effectiveness of interventions aimed at reducing erythema, Nurse Mitchell should focus on inspecting the color and condition of the affected area. Erythema, or redness of the skin, is a visual indicator of inflammation or irritation. By closely monitoring changes in the color and condition of the skin, Nurse Mitchell can directly assess whether the erythema is decreasing as expected. This approach provides specific, observable, and measurable data that align with the established outcome.

Think of monitoring erythema like watching a traffic light. To see if the light changes from red to green (or in this case, the redness of the skin decreases), you need to look directly at the light (the affected area) and observe its color.

Evaluating the color and condition of the skin aligns with the principles of objective assessment and evidence-based practice. This method ensures that Nurse Mitchell gathers relevant and specific information to determine the effectiveness of the care plan and make any necessary adjustments to interventions.

✘Incorrect answer options:

Choosing the right wound care products and techniques. While important for the treatment plan, this action focuses on the intervention itself rather than evaluating the outcome. The effectiveness of these choices should be measured by changes in the erythema.

Daily measuring of the ulcer's diameter. Measuring the ulcer's diameter is important for tracking healing, but it does not directly evaluate changes in erythema. Erythema is specifically about skin redness and inflammation, not the size of the ulcer.

Recording the odor and color of any drainage from the area. Monitoring drainage can provide useful information about infection and healing, but it does not directly measure the decrease in erythema. Focusing on the skin's color and condition is more relevant to the specific outcome of reducing erythema.

References

Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. (2020). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier.
Bickley, L. S. (2017). Bates' Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer.

💡 Hint

Focus on the statement that shows the client consistently applying their understanding over a period of time.

6 / 10

6. Nurse Thompson has identified a nursing diagnosis of knowledge deficit regarding the need to monitor blood glucose levels daily. Which statement best demonstrates the client’s understanding of this necessity?

A. The client agrees to test blood glucose levels four times daily.

B. The client can accurately demonstrate the finger stick technique.

C. The client is seen checking his blood glucose level before breakfast.

D. The client keeps a log of blood glucose levels for a 3-week period.

EXPLANATION

✔Correct answer:

The client keeps a log of blood glucose levels for a 3-week period. The statement that best demonstrates the client’s understanding of the necessity to monitor blood glucose levels daily is "The client keeps a log of blood glucose levels for a 3-week period." This action indicates that the client not only understands the importance of regular monitoring but also consistently follows through with it over an extended period. Keeping a log shows a sustained commitment to managing their health and provides concrete evidence of their understanding and compliance with the necessary routine.

Think of this like a student who keeps a detailed homework diary for several weeks. It shows they understand the importance of doing their homework regularly and are committed to it.

In nursing, evaluating a client's understanding and compliance with health-related instructions involves looking for consistent and sustained behaviors that reflect their knowledge and commitment. Keeping a log of blood glucose levels demonstrates both understanding and the practical application of that knowledge, which are crucial for effective diabetes management.

✘Incorrect answer options:

The client is seen checking his blood glucose level before breakfast. While this shows the client knows how to check their glucose level, it does not demonstrate a sustained understanding and commitment to daily monitoring over time.

The client agrees to test blood glucose levels four times daily. Agreement to test blood glucose levels indicates willingness but does not provide evidence of actual understanding or consistent behavior.

The client can accurately demonstrate the finger stick technique. Demonstrating the technique shows the client knows how to perform the test, but it does not confirm they understand the importance of regular, ongoing monitoring.

References

Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. (2020). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse's Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales (15th ed.). F.A. Davis Company.

💡 Hint

Consider which evaluation directly relates to the outcome of clearing secretions from the airways.

7 / 10

7. Nurse Baker is monitoring a patient diagnosed with impaired gas exchange due to excessive secretions. The goal is for the patient's airways to be clear. To determine if this outcome has been achieved, Nurse Baker should focus her evaluation on:

A. The patient's ability to use incentive spirometry effectively.

B. The patient's complaints of chest pain.

C. Whether the patient's lungs are clear bilaterally upon auscultation.

D. The patient's respiratory rate.

EXPLANATION

✔Correct answer:

Whether the patient's lungs are clear bilaterally upon auscultation. To determine if the outcome of clear airways has been achieved for a patient with impaired gas exchange due to excessive secretions, Nurse Baker should focus on whether the patient's lungs are clear bilaterally upon auscultation. Auscultation of the lungs provides direct and objective evidence of airway clearance. Clear lung sounds indicate that there are no significant secretions or obstructions in the airways, which confirms that the goal of clear airways has been met.

Think of auscultating the lungs like checking the plumbing in a house. Clear pipes (lung sounds) indicate that there are no blockages (secretions), ensuring that everything is flowing smoothly (airways are clear).

Using auscultation to evaluate lung clarity is a key component of respiratory assessment and is essential for diagnosing and monitoring conditions related to gas exchange. This method provides accurate, real-time information about the patient's respiratory status and helps guide further care decisions.

✘Incorrect answer options:

The patient's complaints of chest pain. While chest pain is important to monitor, it does not directly assess airway clearance or the effectiveness of secretion management.

The patient's ability to use incentive spirometry effectively. Effective use of incentive spirometry is a valuable tool for promoting lung expansion and secretion clearance, but it does not provide direct evidence of airway clearance. Auscultation is needed to confirm the outcome.

The patient's respiratory rate. Respiratory rate is an important vital sign to monitor, but it does not provide specific information about the presence or absence of airway secretions. Clear lung sounds are a more direct measure of airway clearance.

References

Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. (2020). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier.
Bickley, L. S. (2017). Bates' Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer.

💡 Hint

Focus on reinforcing positive progress while planning further steps.

8 / 10

8. Nurse Carter is working with a client who has almost reached their goal of reducing smoking to half a pack per day but hasn't fully met it yet. To help the client achieve their target, what should Nurse Carter consider as the most effective nursing intervention?

A. Suggest the client try a new nicotine replacement therapy without further assessment.

B. Provide continuous positive reinforcement for the progress made and develop a plan for the next steps.

C. Advise the client to increase their caffeine intake to reduce cravings for cigarettes.

D. Encourage the client to stop smoking immediately and set a new, more aggressive goal.

EXPLANATION

✔Correct answer:

Provide continuous positive reinforcement for the progress made and develop a plan for the next steps. The most effective nursing intervention for Nurse Carter is to provide continuous positive reinforcement for the progress the client has made and develop a plan for the next steps. Positive reinforcement acknowledges the client’s efforts and achievements, which can boost their confidence and motivation to continue working towards their goal. Additionally, developing a plan for the next steps helps to create a structured and supportive pathway for the client to follow, addressing any challenges they may face and reinforcing their commitment to reducing smoking further.

Think of this process like encouraging a student who has improved their grades significantly but hasn’t yet reached an A. Praising their progress and helping them develop a study plan for further improvement can motivate them to achieve their ultimate goal.

This approach aligns with the principles of motivational interviewing and behavior change, which emphasize the importance of positive reinforcement and incremental progress. By recognizing the client’s achievements and collaboratively planning the next steps, the nurse can support sustainable behavior change and enhance the client’s sense of self-efficacy.

✘Incorrect answer options:

Suggest the client try a new nicotine replacement therapy without further assessment. This option may not be appropriate without assessing the client’s specific needs, preferences, and potential reactions to different therapies. A personalized approach is essential.

Encourage the client to stop smoking immediately and set a new, more aggressive goal. An aggressive approach may be unrealistic and could potentially set the client up for failure, leading to frustration and discouragement. Gradual progress and realistic goals are more effective.

Advise the client to increase their caffeine intake to reduce cravings for cigarettes. Increasing caffeine intake is not a recommended strategy for managing smoking cravings and could lead to additional health issues. It is important to use evidence-based interventions.

References

Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. Guilford Press.
Prochaska, J. O., & Velicer, W. F. (1997). The Transtheoretical Model of Health Behavior Change. American Journal of Health Promotion, 12(1), 38-48.

💡 Hint

Focus on the goal that directly pertains to a standard measure of care, particularly concerning routine monitoring and prevention.

9 / 10

9. Nurse Bailey is formulating goals for her patients, ensuring each is aligned with clinical standards of practice. Which of the following goals is best based on such standards?

A. The client’s chronic pain will be managed using oral medication by the time of discharge.

B. The client will lose 10 pounds within 90 days.

C. The client’s peripheral intravenous (IV) site will show no signs of redness.

D. The client will walk 30 feet with minimal assistance.

EXPLANATION

✔Correct answer:

The client’s peripheral intravenous (IV) site will show no signs of redness. The goal that is best based on clinical standards of practice is "The client’s peripheral intravenous (IV) site will show no signs of redness." This goal is specific, measurable, attainable, relevant, and time-bound (SMART). It directly addresses a common clinical concern related to IV therapy, which is ensuring the site remains free of complications such as infection or phlebitis. Monitoring for redness at the IV site is a standard practice in clinical care to prevent and promptly address potential complications.

Think of this goal like ensuring a planted tree remains healthy by regularly checking the soil and surrounding area for any signs of pests or disease. Just as this practice helps keep the tree healthy, regularly checking the IV site helps ensure the patient’s safety and well-being.

Setting goals based on clinical standards of practice ensures that patient care is guided by evidence-based criteria and best practices. Goals should be clear and precise to facilitate monitoring and evaluation, thereby ensuring optimal patient outcomes. Preventing complications at an IV site aligns with clinical standards for maintaining patient safety and effective care delivery.

✘Incorrect answer options:

The client’s chronic pain will be managed using oral medication by the time of discharge. While managing chronic pain is important, this goal is somewhat vague and lacks specificity regarding how pain will be measured or what level of pain management is considered acceptable.

The client will walk 30 feet with minimal assistance. This goal is specific and measurable but may not align with clinical standards for all patients, as it needs to be tailored to individual capabilities and conditions. It also lacks a clear timeframe.

The client will lose 10 pounds within 90 days. While weight loss can be a health goal, it may not be directly tied to immediate clinical standards of practice for most patients in a hospital setting. Additionally, weight loss goals should be approached with caution and personalized to the patient’s health status and needs.

References

Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. (2020). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier.
Carpenito, L. J. (2016). Handbook of Nursing Diagnosis (15th ed.). Wolters Kluwer.

💡 Hint

Consider which statement directly relates to observing and reporting on the specific goal of walking without respiratory issues.

10 / 10

10. Nurse Thompson is reviewing her patient's progress in physical therapy after a recent lung surgery. She needs to provide an objective evaluation of the patient's ability to walk without experiencing shortness of breath, indicating goal attainment. Which statement should she include in her report?

A. "The patient walked smoothly and reported no issues during the activity."

B. "The patient showed no signs of respiratory distress while walking."

C. "The patient did not exhibit any nausea while walking in the hallway."

D. "The patient experienced no pain following walking sessions."

EXPLANATION

✔Correct answer:

"The patient showed no signs of respiratory distress while walking." The most objective and relevant statement for Nurse Thompson to include in her report is "The patient showed no signs of respiratory distress while walking." This statement directly addresses the patient's ability to walk without experiencing shortness of breath, which is a key indicator of respiratory function and goal attainment following lung surgery. It provides clear, observable evidence that the patient's breathing is not adversely affected by physical activity, which is crucial for assessing progress in recovery.

Imagine evaluating a car’s performance after engine repair. You would check if the car runs smoothly without any unusual noises or issues (like respiratory distress) to confirm the engine is functioning well. Similarly, checking for the absence of respiratory distress confirms the patient’s ability to walk without breathing issues.

In nursing, objective evaluations are based on observable and measurable signs. The absence of respiratory distress while walking is an important clinical indicator of the patient's recovery progress and functional ability. This aligns with the principles of evidence-based practice and thorough patient assessment, ensuring that care plans are effectively meeting the patient's needs.

✘Incorrect answer options:

"The patient walked smoothly and reported no issues during the activity." While this statement is positive, it is somewhat vague and does not specifically address respiratory function, which is critical after lung surgery.

"The patient experienced no pain following walking sessions." Pain management is important, but this statement does not address the specific goal of evaluating respiratory function and shortness of breath during walking.

"The patient did not exhibit any nausea while walking in the hallway." Absence of nausea is beneficial, but it does not provide information about the patient’s respiratory status or ability to walk without shortness of breath.

References

Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. (2020). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier.
Bickley, L. S. (2017). Bates' Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer.

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Notes

🩺 Introduction to the Evaluation Phase of the Nursing Process

🔍 What You’ll Learn in This Topic:

🎯 Purpose of the Evaluation Stage

🩺 Why Do We Evaluate?

🧠 Relatable Example

🔄 Evaluation Isn’t Just an End—It’s a Feedback Loop

🧠 Memory Trick – Think “G.A.P.E.”

✏️ Student Mini Worksheet

📏 Establishing Evaluation Criteria and Standards

🧠 Example to Bring It to Life

🔍 Key Concepts:

🧠 Memory Trick – “C.R.I.T.”

📋 Clinical Practice Tip:

✏️ Student Mini Worksheet

📊 Collecting and Interpreting Patient Outcome Data

🔍 Step-by-Step Breakdown

1. Collect Data Systematically

2. Use Multiple Sources

3. Compare with Expected Outcomes

4. Interpret the Meaning

🧠 Real-Life Example

🧠 Memory Trick – Use D.A.T.A.

💡 Pro Tip:

✏️ Student Mini Worksheet

🎯 Determining Goal Achievement: Met, Partially Met, Unmet

1. Goal Met

2. Goal Partially Met

❌ 3. Goal Not Met

🧠 Memory Trick – M.P.U. = Measure Patient’s Upshot

📈 Think Like a Nurse: Ask Yourself

✏️ Student Mini Worksheet

📝 Documenting and Reporting Evaluation Findings

📋 What Should Be Documented?

🧠 Example of a Good Evaluation Note:

💬 Reporting to the Team

📌 Tips for Effective Documentation:

🧠 Memory Trick – Use “G.R.A.D.E.” when documenting evaluation:

✏️ Student Mini Worksheet

🔄 Modifying the Plan of Care Based on Evaluation

🔍 When to Modify the Plan

🧠 Example:

🔁 What Can Be Modified?

💡 Memory Trick – “R.E.N.E.W.” your Plan

🧠 Quick Clinical Scenario:

✏️ Student Mini Worksheet

🧠 Memory Trick Recap: Key Mnemonics to Remember

📋 All-in-One Interactive Worksheet: Evaluation Practice

💡 FAQs: Evaluation Phase (Based on Common Student Searches)

Exam

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