Help w/ Evaluations/NANDA!!!

[Nursey103, ADN, RN]

I'm having trouble writing an evaluation on whether or not my outcome was achieved.

I followed a patient from pre-op to the OR and then to the PACU.

Here is what I have so far...

Risk for infection R/T laparoscopic surgical intervention & foley catheter insertion

Expected Outcome: Patient will remain free from symptoms of infection.

Nursing Interventions:

Patient to receive IV antibiotics (Ancef) prior to surgery

Alcohol-based prep to be used to clean abdomen prior to laparoscopic surgery

Cleanse & prep lady partsl area prior to inserting foley catheter

Maintain sterile technique while inserting foley catheter

Evaluation: ?!?

I was only with the patient for one hour post-op so how would I be able to properly evaluate if the patient remained free from infection - bacteria wouldn't act that fast! haha....I need help!!

[C. Thinking]

I'm having trouble writing an evaluation on whether or not my outcome was achieved.

I followed a patient from pre-op to the OR and then to the PACU.

Here is what I have so far...

Risk for infection R/T laparoscopic surgical intervention & foley catheter insertion

Expected Outcome: Patient will remain free from symptoms of infection.

Nursing Interventions:

Patient to receive IV antibiotics (Ancef) prior to surgery

Alcohol-based prep to be used to clean abdomen prior to laparoscopic surgery

Cleanse & prep lady partsl area prior to inserting foley catheter

Maintain sterile technique while inserting foley catheter

Evaluation: ?!?

I was only with the patient for one hour post-op so how would I be able to properly evaluate if the patient remained free from infection - bacteria wouldn't act that fast! haha....I need help!!

It is good if you keep your "expected outcome" statements within measurable range. For you, as a student, that would mean things you could evaluate in the short time you cared for the patient.

For example, you could say as an "Expected Outcome": Patient will remain s/s free of infection on evidenced by T>97.8F, 60bpm, 24bpm, 30ml/hr.

This will give you actual assessment data to evaluate your expected outcome properly as temp may be elevate/low with infection, HR-RR would increase in systemic infection, urine should be clear w/o sediment, straw colored, w/o foul odor, and 30ml/hr is the minimum you want to see from your patient. These are all great measurments for s/s of infection and are easily assessed.

Then your evaluation would simply be the assessments made pertaining to your expected outcome.

For example of example above: "Pts T- 98.4 O, 98.2 O. HR - 77bpm, RR - 20bpm. Foley draining to gravity with 400ml - clear, straw colored urine."

[Nursey103, ADN, RN]

Thank you...that's really helpful! It's tough getting used to writing these nursing diagnoses :thnkg:

[Daytonite, BSN, RN]

your diagnosis is risk for infection. your interventions are designed to prevent what specific infection from occurring? it looks like you are trying to prevent a uti as a result of the foley insertion and tissue infection when the skin is cut by the surgeon. the predicted outcome is that the patient will be free of those infections, right? how do you know? you assess for signs and symptoms of them. thus, your evaluation is to assess for the presence of the signs and symptoms of a uti and infected laparoscope incisions. that assessment would need to be normal, as opposed to abnormal (signs and symptoms of infection). note: your interventions should include monitoring the patient for the specific signs and symptoms of infection of these two areas. see this post on how to compose goal statements and write interventions for "risk for" diagnoses: https://allnurses.com/forums/2509305-post158.html and https://allnurses.com/forums/2751313-post8.html

• at ____am no evidence (list specific s/s) of a uti were noted and foley was draining clear, yellow urine.
  
• at ____am the laparoscopic incisions were well-approximated with no redness, swelling, drainage and patient was afebrile.