NURSING

EVALUATION
DEFINITION
The evaluation stage is a systematic and planned comparison of the client's health with the goals that have
been set, carried out continuously by involving the client and other health workers. The evaluation will
assess nursing actions to determine the client's progress toward achieving goals and outcomes and assess
the effectiveness of the nursing care plan in meeting the client's needs.
PURPOSE
1. To determine the development of the client's health from time to time
2. To assess the effectiveness, efficiency, and productivity of nursing actions that have been given.
3. To assess the implementation of nursing care.
4. To get feedback for the nursing process.
5. As a responsibility and accountability in the implementation of nursing services.
STEPS
1. Reviewing Client data
The assessment is carried out continuously and continuously every time you contact the client. Assessment at the evaluation stage is focused on
comparing with the goals that should be achieved by the client. Measurement of the achievement of evaluation objectives includes:
a. Knowledge (cognitive): Interview Client's knowledge of the disease:
1) Signs and symptoms
2) Control the symptoms
3) Medication and diet
4) Activity
5) Availability of tools and resources
6) Complication risk
7) Symptoms to report
8) Prevention

a. Affective (emotional status): Direct observation, Interview

1) Response to disease
2) Coping mechanism
3) Coping source
b. Psychomotor: Direct observation of the client's ability to self-care
c. Changes in body functions and symptoms: direct observation, interview, physical examination
STEPS
2. Comparing data with defined goals/results
Both the nurse and the client compare the client's actual response with the expected outcome. This comparison leads to the following possible
conclusions:
a. Goal achieved: the client's response is the same as the expected result.
b. Goals partially achieved; short-term goals are achieved, but long-term goals are not achieved, or the expected results are partially achieved
c. Goal not achieved.

After determining whether the goals have been achieved, the nurse writes an evaluation statement consisting of two parts: conclusions and supporting
data. Conclusion is a statement that the objectives/results are achieved, partially achieved, or not achieved. Supporting data is a list of client responses
that support the conclusion.

If the NOC indicator is used on the outcome, the scores on the scale after the intervention are compared with the scores measured on the standard to
determine improvement. In the modification of the nursing care plan, there is a rationale for continuing, modifying, or changing the client's nursing plan
STEPS
3. Linking nursing actions with outcomes

The nurse determines whether nursing actions have a relationship with outcomes. Nursing action is not the only factor that determines whether the goal
is achieved or not, if the action is considered ineffective then the nurse needs to look at the procedural process of the action whether it is in accordance
with the standards, identify the supporting and inhibiting factors of the success of therapy. Possible specific causes need to be assessed in relation to the
client's level of knowledge, ability and willingness and the availability of resources.
4. Drawing conclusions about the status of the problem

The nurse uses an assessment of goal attainment to determine whether the plan of care is effective in resolving, reducing or preventing the client's
problems. Alternative conclusions about the client's problem status:
a. The client has achieved the results specified in the objectives:
1) The actual diagnosis has been completed or the potential problem has been prevented and the risk factor has ceased to exist. The nurse
documents the goals achieved and stops care for the problem
2) Potential problems can be prevented but risk factors are still present. The nurse maintains the plan of care so that problems do not become
actual.
b. Goals partially achieved or not achieved:
1) revisions may be required during the assessment, diagnosis, planning and implementation phases
2) The plan of care does not need to be revised, because the client needs more time to achieve the goals set
3) The client is still in the process of achieving the specified result

a. The client cannot achieve the specified result:

1) Review problems or responses that have been accurately identified
2) Creating a new outcam
3) Nursing interventions should be evaluated in terms of their appropriateness to achieve the stated goals.
5. Making plans
Based on conclusions about the status of the client's problem, the nurse determines whether the follow-up plan is: continued, modified, or terminated.
Modifications can be made by crossing out a section of the plan of care or marking the section with a light color pen and writing a follow-up note, dated.
6. Evaluation documentation

One format that can be used for evaluation documentation is SOAP:

S : Subjective, information in the form of expressions obtained from the client after the action is given.
O : Objective, The information obtained is in the form of observations, assessments, measurements made by nurses after the action is taken
A : Assessment, Assessment or analysis of subjective and objective data is compared with the goals and criteria for the results and then conclusions
are drawn whether the objectives are achieved, partially achieved or not achieved.
P : Planning, follow-up nursing plans to be carried out based on the conclusions of the analysis.