Page 29 - Advanced Communication in Nursing

Reading

Reading a text about how to write evaluation
a.
Read the text about the nursing diagnosis of a patient. Fill in the blanks to sum up the text

How to Write Evaluation in Nursing Care Plan
The fifth and final step of the nursing care plan is the evaluation phase. This is when you
evaluate if the desired outcome has been met during the shift. There are three possible
outcomes,
• Met
• Ongoing
• Not Met
Based on the evaluation, it can determine if the goals and interventions need to be altered.
Ideally, by the time of discharge, all nursing care plans, including goals should be met.
Unfortunately, this is not always the case - especially if a patient is being discharged to hospice,
home care, or a long-term care facility. Initially, you will find that most care plans will have
ongoing goals that might be met within a few days or may take weeks. It depends on the status
of the patient as well as the desired goals.
Consider picking goals that are achievable and can be met by the patient. This will help the

patient feel like they are making progress but also provide relief to the nurse because they can
The goals Reason
track the patient’s overall progress.
Met 1.

Ongoing 2.
Not Met 3.
b.
Decide whether the intervention has met the goals or not. Provide the reason(s).

Assessment
Subjective:
• The Pt said, “Sometimes my leg hurts.”
Objective:
• Pain scale: 7/10
• Facial grimace
• Guarding behavior
Nursing diagnosis
Acute pain r/t irritation of nerve endings secondary to surgical procedure as evidenced by pain scale of
7/10

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