evaluation....

Published

Hi.

in my case study I have divided ( specified) ex.

nursing goals:

1. Client will have improved cerebral tissue perfusion.

2....

3......

and

[TABLE=class: cms_table_cms_table]

[TR]

[TD]Outcomes[/TD]

[TD][/TD]

[/TR]

[TR]

[TD]1.Cerebral function improved, neurological deficits resolving/stabilized

for example Pt will.....

a.Demonstrate ability to follow simple commands

b.Demonstrate appropriate orientation to person, place, time, and situation

[/TD]

[/TR]

[/TABLE]

2.....

3.........

and now what to do? should I evaluate nursing goals or

should I evaluate outcomes.....??? and how?

Am I correct? help pls...............

Up Vote Up Vote ×

I think you're stuck because you're looking for nursing diagnosis and care for a medical diagnosis. It doesn't work like that. Nursing diagnosis and plan of care comes from nursing assessment.

There is a nursing diagnosis for "Risk for ineffective cerebral tissue perfusion," defined as being "at risk for a decrease in cerebral tissue circulation that may compromise health." But I'm not sure that's what you're working with. Is it?

Improved cerebral perfusion sounds more like a medical goal. Great idea, but outside of some specific ICU-type interventions I can't think of much in the way of nursing interventions that will make blood flow better in the brain or guarantee resolution of neurological deficits. Correcting medical pathology is the job of the medical plan of care. We support that, but we don't drive it. Remember, this is nursing we're talking about. Better blood flow to the brain is not a nursing goal, broadly speaking. So let's think about the nursing plan of care you're trying to write.

When you look at your patient, what do you observe? Assuming it's a CVA patient, I'm guessing from your list of desired outcomes that perhaps he has neurological deficits. What are they, exactly? What is their effect? What do you want to do about them? Why?

For example, if there's a hemiplegia, what effect does that have on the patient's functional abilities? What would you, the nurse, do about those? If there's disorientation, what would you do to help with that? If there's an unsafe swallow, what would you do?

Now, what are we really talking about here? I'm thinking it's more along the lines of patient safety, prevention of injury, impaired mobility or self-care, that sort of thing. Look those up and see if you can get re-oriented to a better direction. I can't really tell from what you wrote. (any luck getting the NANDA-I book yet?)

Come back and tell us what you think.

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

[TABLE]

[TR]

[/TR]

[TR]

[TD] Introduction (patient and problem)[/TD]

[TD]

  • Explain who the patient is (Age, gender, etc.)
  • Explain what the problem is (What was he/she diagnosed with, or what happened?)
  • Introduce your main argument (What should you as a nurse focus on or do?)

[/TD]

[/TR]

[TR]

[TD] Pathophysiology[/TD]

[TD]

  • Explain the disease (What are the symptoms? What causes it?)

[/TD]

[/TR]

[TR]

[TD] History[/TD]

[TD]

  • Explain what health problems the patient has (Has she/he been diagnosed with other diseases?)
  • Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she on medication?)

[/TD]

[/TR]

[TR]

[TD] Nursing Physical Assessment[/TD]

[TD]

  • List all the patient's health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)

[/TD]

[/TR]

[TR]

[TD] Related Treatments[/TD]

[TD]

  • Explain what treatments the patient is receiving because of his/her disease

[/TD]

[/TR]

[TR]

[TD]Nursing Care Plan[/TD]

[TD][/TD]

[/TR]

[TR]

[TD]

Nursing Diagnosis & Patient Goal

[/TD]

[TD]

  • Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?)
  • Explain what your goal is for helping the patient recover (What do you want to change for the patient?)

[/TD]

[/TR]

[TR]

[TD]

Nursing Interventions

[/TD]

[TD]

  • Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature)

[/TD]

[/TR]

[TR]

[TD]

Evaluation

[/TD]

[TD]

  • Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?)

[/TD]

[/TR]

[TR]

[TD] Recommendations[/TD]

[TD]

  • Explain what the patient or nurse should do in the future to continue recovery/improvement

[/TD]

[/TR]

[/TABLE]

Up Vote Up Vote ×
Improved cerebral perfusion sounds more like a medical goal. Great idea, but outside of some specific ICU-type interventions I can't think of much in the way of nursing interventions that will make blood flow better in the brain or guarantee resolution of neurological deficits. Correcting medical pathology is the job of the medical plan of care. We support that, but we don't drive it. Remember, this is nursing we're talking about. Better blood flow to the brain is not a nursing goal, broadly speaking. So let's think about the nursing plan of care you're trying to write.

you have right, but how about this:

nursing priorities :

1. Promote adequate cerebral perfusion and oxygenation.

which are the actions that nurse must do to accomplish this priority???

and if this is a nursing priority which would be the right nursing goal for this??

Up Vote Up Vote ×
you have right, but how about this:

nursing priorities :

1. Promote adequate cerebral perfusion and oxygenation.

which are the actions that nurse must do to accomplish this priority???

and if this is a nursing priority which would be the right nursing goal for this??

I think a better way to word your nursing diagnosis would be, "(Risk for) Inadequate tissue perfusion".

In order to more adequately supply the tissue/cerebrum with oxygen, what should you do?

For you're goals, what would you like to get out of your interventions? If you give oxygen, would neurological defects (as GrnTea said) be better or worse?

Up Vote Up Vote ×
+ Join the Discussion