Evaluating Patient Response to Plan of Care

Guidelines:

• Evaluation
  • Checking, observing, and appraising the results of interventions
  • Integral, systematic, ongoing
  • Essential for providing safe, effective, quality perioperative nursing care
  • Focuses on the patient’s progress in attaining identified outcomes
  • Should include participation from patient/family when possible
  • Must be documented
  • Evaluation extends through the postoperative period and beyond
  • Essential element of communication, hand-off

Considerations:

• Communication is key during evaluation
  • Briefing
  • Time-out
  • Debriefing
  • Hand-off

Nurse’s role:

• Perioperative RN Evaluation Competencies:
  • Evaluates progress
  • Conducts a systematic and ongoing evaluation measuring the effectiveness of interventions in relation to achieving identified goals and outcomes
  • Monitors and documents patient’s progress toward achieving specified outcomes
  • Revises plan of care based on ongoing assessment and evaluation
  • Involves patient/family in evaluation process
  • Disseminates evaluation results as appropriate
  • Recommends policy, procedure, protocol, process, or structural changes based on evaluation data

Pitfalls:

• Evaluation must be ongoing throughout procedure
• The perioperative must evaluate considering the nursing diagnosis and achievement of identified outcomes
  • It is a process!
• Evaluation provides feedback regarding effectiveness of the plan, its implementation, and alterations needed for improving care
  • Not a one and done, should inform nursing practice modifications
• Evaluation must be shared during hand-off for continuity of care

Examples:

• Evaluation Feedback:
  • Was the patient protected from peripheral neurovascular injury?
  • Was the patient free from perioperative positioning injury?
  • Was adequate oxygenation maintained?
  • Does the patient have more questions pertaining to recovery and rehabilitation?
• Use evaluation to determine the need to maintain or modify the plan
• Outcome statements:
  • The patient was free from peripheral neurovascular dysfunction on discharge to PACU AEB presence of pulses, warmth of extremity, good capillary refill, and intact movement and sensation
• The patient was free from injury related to perioperative positioning AEB maintenance of skin integrity and absence of reddened areas
• The patient maintained adequate ventilation and perfusion AED blood gases, arterial saturation, oxygen saturation, and vital signs WNL
• The patient was free from surgical site infection AEB temperature within normal limits and a clean and dry incision site

Linchpins (Key Points):

• Evaluation
  • Is integral, systematic, and ongoing
  • Should inform your plan of care
  • Should be communicated during hand-off