Help w/ Evaluations/NANDA!!!

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."

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