Chapter 18: Evaluating

When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate?

"Demonstrated steps" Explanation: Written documentation of the subjective and objective data gathered and the judgment made about goal attainment is required on the client's health record. Judgments about goal attainment are written clearly and concisely. Avoid ambiguous terminology, such as "inadequate," "good," or "extremely well," which can be interpreted differently by different people.

The nurse should evaluate client outcomes at which time?

As early as possible. Nurses should evaluate client outcome achievement as early as possible. Celebrating outcome attainment with the client usually helps encourage the client and leads to further outcome achievement. When failure to meet designated outcomes is detected early, the care plan can be modified to remedy the failure. Waiting until the day of discharge may be too late. Evaluating outcomes after the client has been discharged would be difficult. Evaluating outcomes within 24 hours may be too soon or unnecessarily late, depending on the nature of the outcomes.

"The levels of performance accepted by and expected of nursing staff or other health team members" defines:

Standards

A nurse manager tends to use the quality by inspection method of ensuring quality on the unit. Which actions, taken by this manager, are evidence of use of this technique? Select all that apply.

The manager threatens to "write up" a nurse if the nurse is late to work again. The nurse requests transfer off the unit for a nurse who has made three medication errors in three months. Explanation: Quality by inspection focuses on finding deficient workers and removing them. Quality as opportunity focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork. Holding education sessions regarding problem-prone procedures reflects this technique. Not participating in celebrations and making client rounds are not related to either quality style.

Identifying the kind and amount of nursing services required is a possible solution for:

inadequate staffing. Explanation: A possible solution for inadequate staffing is to identify the kind and amount of nursing services required. Using a team conference to develop a consistent plan of care is a possible solution for the client who fails to communicate needs. Educating the client to become an assertive health care consumer is a possible solution for the client who quietly accepts whatever care is delivered or not delivered. A possible solution for the nurse who is a candidate for burnout is to learn to give quality care during the designated work period. An initiative to focus on quality improvement is a possible solution to nurses frustrated with substandard care. Reviewing task assignments and work schedules is a possible solution to bored nurses.

The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered:

structure. Explanation: Availability of equipment, layout of physical facilities, nurse-client ratios, administrative support, and maintenance of nursing staff competence are some areas of concern for structure evaluation. Process, outcome, goal, and subjective evaluation address those respective categories.

Which action should the nurse take when client data indicate that the stated goals have not been achieved?

Review each preceding step of the nursing process. Explanation: If a client's goal has not been achieved the nurse should review each of the preceding steps of the nursing process in order to try to identify the contributing factors causing problems with the plan of care. By conducting the evaluation this way, the nurse may find that more data must be collected or the plan of care needs revision. An individualized plan of care rather than a standardized plan of care is often warranted.

Which nurse is using criteria to determine expected standards of performance?

The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. Explanation: Standards are the levels of performance accepted and expected by the nursing staff and other health team members, such as institutional policies and procedures. The nurse preceptor providing feedback to the new graduate nurse after 6 weeks of orientation is an example of peer review. The nurse manager providing the staff nurse feedback regarding job performance for the previous year is typical of an annual employee review. The nurse seeking input from the UAP on a family's response to education is inappropriate, as the nurse may not delegate evaluation to the UAP.

A new mother is having difficulty breastfeeding a newborn infant. A goal was established stating that the baby would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports having discontinued breastfeeding. The nurse evaluates the original goal as:

completely unmet. After collecting data and evaluating the client's behavioral responses, the nurse makes a judgment about goal attainment by comparing the client's actual behavioral responses with the predicted responses or predetermined outcome criteria developed in the planning phase. In this case the mother abandoned breastfeeding, which represents a complete failure to meet the collaborative goal established. If the mother reported breastfeeding the baby every 4 to 5 hours, the nurse could consider the goal partially met. There is no evidence that the goal was inappropriately chosen for the client.

A client comes into the clinic for a routine postoperative visit. While the nurse is assessing the level of pain, the client states that there is occasional discomfort but that pain levels have improved daily since returning home from the hospital. What should the nurse's response be regarding the client's plan of care?

Continue the plan of care. Explanation: The nurse should continue the plan of care, as the client is progressing toward the ultimate outcome—the healing of the surgical site. There is no need to modify the plan, as the client is responding. The client is still having some pain, so it would not be appropriate to discontinue the plan of care. With the improvement in the client's pain, there is no need to increase pain medication; the nurse should just remind the client to take it when pain is uncomfortable.

The nurse manager observes one of the unit nurses failing to wash hands on entering a client room. Hospital protocol is to wash hands before and after entering a client room. This scenario is an example of which approach to quality assurance?

Quality by inspection Explanation: Quality by inspection is an approach to quality assurance in which nurses watch for deficient workers and remove them in an effort to prevent harm to clients. Quality as opportunity, on the other hand, focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned. Quality by perception and quality as initiative are not specific approaches to quality assurance.

The nurse determines that the client is not meeting some of the expected outcomes in the plan of care. What are the next steps in the process? Select all that apply.

Reevaluate each step of the nursing process. Identify contributing factors. Collect additional data. Add or alter nursing diagnoses. Explanation: There would not be a need to delete all of the expected outcomes. The ones that the client is not making progress toward meeting may need to be altered, but it would not be necessary to delete them all. The other choices would be appropriate in modifying the plan of care.