Ok, I have just about completed my first "complete" care plan. I just have a question if I'm doing the evaluation stage correctly. My client has pneumonia and the goal is "client will have improved gas exchange by 11-17-06" outcome: "the patient will show a measurable improvement of gas exchange by the use of less oxygen". Would a correct evaluation be "partially met. Patient's gas exchange has shown a measurable improvement by the reduction of oxygen to 1 L/min" 11-17-06? Keep in mind this is just practice and we are just pretending its 2 weeks later, since we only have 1 patient each week.
Also should I mention that the patient is on 2L/min of oxygen in the outcome or not since I did mention it in the prioritized list?
Nov 6, '06
i would re-word the outcome: the patient will have improved breathing by 11-17-06 as evidenced by abgs on supplemental oxygen that are within normal parameters.
outcomes are the predicted results of independent nursing actions. independent nursing actions are those things that a nurse does for a patient that do not require a physician order. an expected outcome is measurable, patient centered, and specific. when you identify an outcome, you accept responsibility and accountability for helping the patient achieve that outcome. you can mention oxygen in your outcome statement, but what is important is the nursing interventions that are going to lead to that outcome.
your evaluation needs to be something that is measurable and factual. "the patient's abgs on 1l of oxygen on 11-17-06 were normal (or list out normal levels)." or "on 1l of oxygen the patient showed no evidence of cyanosis, dyspnea, tachycardia, restlessness or diaphoresis (symptoms of hypoxia)."