Care Plan (Patient Response to Nursing Intervention)

[knowethzani]

Hello all!!!

I know that there are several topics on this which I have looked at a few and am still kinda stumped lol.

Im in nursing school nearing the end of my first year with my first rotation of clinicals. I have a patient for whom I have written a care plan for and turned in the rough draft.

While waiting to get it back I cant help but wonder about the 'Evaluation/Patient Response'. I just dont really understand what I am supposed to put for that piece of my care plan.

Example:

NDx-Risk for falls, related to diminished mental status (dementia), as evidenced by history of falls

Interventions- clear clutter, encourage ambulation aids and eyewear usage, and put things of common use like call light, phone, remote, etc. within reach. I have rationales for each of those interventions.

The next column says evaluation/patient response. Which is where I am stumped.

Of course I cant just say 'goal met', which is understandable. The point of the post is not to have you guys do this piece for me. I guess I am just wanting to know the guidelines to this piece. How to go about this part. I have the rubric but this is the only portion the rubric does not elaborate on. I have talked to my instructor prior to handing it in and she just said "Turn it in and let me see what you've got" She didnt really explain.

Should I elaborate on what happened after I implemented the interventions? How it went? Or am I just supposed to document whether the pt was receptive and cooperative of the interventions? And what if for my other interventions, goals were not met...do I say that and why I believe it did not go as planned? Or am I wayy left field?

Im sure I am just over thinking it and maybe it is more simple than it appears. Maybe I am just having a brain fart. I could really use the advice. Of course my instructor will give me feed back and elaborate but I would also like to get help from others too.

Thank you in advance for your advice and guidance.

[NICUismylife, ADN, BSN, RN]

My instructors require that next to every intervention, you evaluate how that evaluation went. It's okay if it didn't turn out well. I've literally had to write: "I didn't have time to do this intervention due to (insert reason here: pt had to go for CT scan, coded, was in severe pain and couldn't concentrate on education, etc.)." Or simply "This intervention was ineffective because (insert reason here), next time I would try (different intervention) instead." They don't necessarily want to hear that everything went as planned, that's not real life. They want to know that you can evaluate and change your plan effectively.

So, I would be required to write:

Intervention: Encourage ambulation aids. Evaluation: Patient verbalized understanding of importance of using walker during ambulation, and displayed proper usage during my shift.

Personal effects within reach: Patient was able to easily reach all personal effects and did not attempt to get out of bed without assistance in order to reach anything.

Call light in reach and answer immediately: Patient's call light remained in reach at all times and was answered immediately.

Fall risk signs, socks, wrist band in place: Patient continually pulled off fall risk socks, and complained that they were too big and uncomfortable. I got her a smaller pair and she wore them for the rest of my shift. Sign and wristband remained in place.

Educate patient on fall risk reduction at home including removing area rugs, effective lighting, using hand rails, ensuring no loose cords, etc.: Patient and family verbalized understanding of teaching and pointed out areas of their home that they would make changes to.

Final goal: Met. Patient did not fall during my shift.

[knowethzani]

This finally makes a lot of sense!

Thank you for your help!