Thursday, April 12, 2012

CPNE: Evaluations and Rationales

This is Sheri doing her thing and breaking down evals.


Moving on to the final part of documentation, your evaluation form with rationales. Just thought I'd write out the ones that I used for my 3 PCS's and then a couple of the ones I used for practice care plans for reference. The main thing I focused on in careplans was to ensure that my evaluation would be a piece of cake, I never picked a diagnostic label that would or could possibly set me up for a challenge at eval because I figured if you made it that far the last thing you want to do is mess up the eval!I made sure, as best as I could, that I'd be able to check that "effective" box when I selected my interventions, I wanted to avoid the 'not effective' and 'unmet' options like the plague.

For evals you're basically restating what you did in reference to your label and whether or not the patient moved toward the outcome. I copied over my planning phase care plan verbatim for the applicable areas and went from there.  They will sound redundant, that's OK. Same for rationales, after you get a few under your belt you will use the same wording in all of them, don't try to reinvent the wheel if it works run with it!


PCS #1 Evalution: (Choices were Impaired Gas Exchange & Activity Intolerance)

Nursing Diagnostic Label: (copied exactly from my planning phase)
Impaired Gas Exchange

Related Factor:
Ventilation perfusion imbalance-COPD


Signs & Symptoms:

Patient complains of dyspnea and fatigue.

Outcome:
Patient will have a capillary refill of less than 3 seconds in both hands during PCS

Patient's progress toward the expected outcome:

MET
Patient had a capillary refill of less than 3 seconds during PCS.

Intervention #1:
Nurse will continue to administer oxygen as ordered via nasal canula during PCS
 
Evaluation of effectiveness of interventions in moving the patient toward the expected outcome:
Effective
Oxygen was administered as ordered via nasal canula and patient had a capillary refill of less than 3 seconds in both hands during PCS.

Intervention #2:
Nurse will offer rest periods during ambulation during PCS.

Evaluation of effectiveness of interventions in moving the patient toward the expected outcome:

This one was a little tricky since my patient went crazy, I debated about checking the effective box because I DID offer the rest periods and the outcome was achieved, I probably could've gotten away with that but I opted to include a little detail about what actually happened just to be on the safe side.
Effective (I did check effective)

Rest periods were offered throughout ambulation and although the patient declined the need to rest his capillary refill remained less than 3 seconds in both hands during PCS. Continuing to encourage rest with activity will improve oxygenation.



Rationale explaining whey this nursing label is a priority diagnosis for this patient during the PCS.
Effective oxygenation is a basic physiological need in order to deliver oxygen to the tissues for vital functioning. By continuing to administer oxygen and encouraging rest during activity the patient will be able to maintain a higher level of oxygen perfusion which will aid in recovery and decrease the chance of further complications.


PCS #2 Evaluation: (Choices were Acute Pain & Activity Intolerance)



Nursing diagnostic label:


Acute Pain


Related Factor:




Tissue Trauma- abdominal surgery


Signs & Symptoms:


Patient states pain level 4 on 0-10 scale.


Expected Outcome:
Patient will rate pain level 3 or less on 0-10 scale during PCS
Patient's progress toward the expected outcome:
MET
Patient rated pain at a level "0 to 1" on a 0-10 scale after implementing interventions during the PCS and states that she feels "wonderful" and can't believe the difference in how she feels in just 1 day.


Intervention #1:


Encourage patient to use PCA pump at regular intervals to better manage pain during PCS.


Evaluation of effectiveness of interventions in moving the patient toward the expected outcome:
Effective

Patient was encouraged to use the PCA pump regularly to better manage pain and reports feeling "wonderful" with pain at a level "0-1" on a 0-10 scale.



Intervention #2:
Reposition patient out of bed to chair x 1 during PCS.
Evaluation of effectiveness of interventions in moving the patient toward the expected outcome:
Effective

Patient repositioned out of bed to chair during PCS and reports feeling "wonderful" with a pain at a level "0-1" on a 0-10 scale.

Rationale explaining whey this nursing label is a priority diagnosis for this patient during the PCS.
Freedom from pain is a basic human right and physiological need in order for the body to maintain a state of homeostasis. If pain is not managed at an acceptable level the patient is at risk for further complications including prolonged immobility that can lead to dvt's, pneumonia, and atelactasis which will delay recovery and prolong hospitalization.



PCS #3 Evaluation (Choices were Impaired Gas Exchange & Activity Intolerance, again)

Nursing diagnostic label:


Impaired Gas Exchange


Related Factor:




Ventilation perfusion imbalance- COPD

Signs & Symptoms:


Patient complaints of severe dyspnea.

Expected Outcome:
Patient will have an oxygen saturation of 92% or higher on oxygen during PCS
Patient's progress toward the expected outcome:
MET
Patient had an oxygen saturation of 92% on oxygen during PCS.


Intervention #1:


Continue to administer oxygen as ordered via NC during PCS.


Evaluation of effectiveness of interventions in moving the patient toward the expected outcome:
Effective

Oxygen was administered via nasal canula at 1.5L/min as ordered and patient had an oxygen saturation of 92% during PCS.



Intervention #2:
Nurse will position patient upright out of bed to chair x1 to facilitate oxygenation during PCSEvaluation of effectiveness of interventions in moving the patient toward the expected outcome:
Effective

Patient repositioned out of bed to chair during PCS and had a oxygen saturation of 92%.

Rationale explaining whey this nursing label is a priority diagnosis for this patient during the PCS.
Effective gas exchange is a basic physiological need necessary to perfuse oxygen throughout the body for cellular functioning. Without adequate oxygenation the patient is at risk for extensive complications including cellular death and decreased cardiac output which is further complicated by the patients COPD and CHF.



Some other rationales for reference: See how they all start to sound the same??




Ineffective Airway Clearance:
A patent airway is a basic physiological need in order to deliver oxygen to the body for cellular functioning. Continuing to perform respiratory hygiene activities and positioning the patient upright will further loosen secretions and facilitate proper oxygenation of the tissues which will increase recovery and prevent further complications including pneumonia and atelactasis.
 
Ineffective Peripheral Tissue Perfusion:
Adequate circulation is a fundamental biological need for the body to deliver nutrients and oxygen to the tissues for cellular functioning. Without appropriate distribution of circulation to the peripheries the patient is at risk for further complications including tissue necrosis and thrombi formation that will delay recovery and prolong the hospital stay

Imbalanced Nutrition Less Than Body Requirements:
Adequate nutrition is a basic physiological need in order to meet body requirements for cellular growth and homeostasis. Keeping intracranial pressure within normal limits with the use of ordered medications and proper positioning will stabilize the patient’s internal regulatory mechanisms and encourage the patient to resume a normal appetite. By continuing to offer the patient formula at regular intervals the patient will have the ability to ingest adequate nutrition to promote healing and prevent further complications.

Acute Pain (another version):
Freedom from pain is a basic human right and important physiological need. Failure to manage pain appropriately can delay patient recovery, worsen mobility impairments and lead to serious complications such as deep vein thrombosis and pneumoni

This is part of my post series on Excelsior College's ADN nursing program and the CPNE experience. See all related posts over here. 





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