The first three steps of the nursing process are assessment, diagnosis and care planning. These must be done so we know what to do to make our patients get well. But we cannot stop there. If we are to accomplish our goal of delivering high quality patient care, we must make sure our interventions worked. We cannot forget to evaluate. Here are some real life examples from nursing practice:
A patient is wheezing. A prn nebulizer treatment using a bronchodilator is administered. The nursing note reads, “Neb treatment minimally effective.”
What questions would you have for the nurse who wrote this note?
“What does minimally effective mean?” “Did you listen to the patient’s lungs before the treatment and after?” What other symptoms did the patient have such as shortness of breath, increased respiratory rate or decreased oxygen saturation, and are they improved? Wouldn’t a better note be, “Wheezes on inspiration and expiration present before treatment diminished only slightly after the nebulizer treatment.” “What is your next step?” If the patient is in some respiratory distress, and he might be with this amount of wheezing, call his primary health practitioner for something else to relieve his wheezing. Sometimes I see nurses who hear wheezing without a stethoscope and never directly listen to the patient’s lungs. This wheezing sound is usually coming from congestion in the upper airways and not from the lungs. An accurate evaluation of the effect of a bronchodilator cannot be made without listening to the patient’s lungs.
A patient is in pain. A prn narcotic analgesic is given. There is no note documenting the effectiveness of this medication or the nursing note reads that the medication effect was fair.
What kind of documentation do you do under these circumstances?
A better way to evaluate effectiveness of a pain medication is to ask more questions about the pain before administering the analgesic. Where is it? What does the pain feel like, achy, sharp, burning? How severe is it? Does it radiate and where? What makes it better or worse? If you use a scale, and the patient said his pain was a 7 before the analgesic and only went down to a 5, that’s what you would document. But don’t stop there. You wouldn’t want to be in that much pain. Does he need another pain pill? If he has taken the maximum amount of medication, and his health care practitioner has been called, are there any environmental interventions the patient has used in the past to reduce pain? If the patient states that standing increases his pain, but lying down reduces it, get the patient into a lying position.
A patient is diagnosed with a monilial rash in his groin. The nurses apply the prescribed ointment every day for two weeks but never document on whether the rash is better or worse. A month later the rash is back, but it is unclear if the rash ever resolved in the first place.
Without knowing if the first treatment was effective, we don’t know whether to start the same treatment again or use another one. There is also no documentation of what else the nurses have done such as leaving the area open to air or making sure to keep this area as dry as possible. This is a waste of valuable time if our goal is to get rid of this rash permanently.
A patient is depressed. An antidepressant is started. There is no nursing documentation on if the patient’s signs and symptoms of depression are better or worse.
To know if this drug was effective, we need to know what signs and symptoms were present before the medication was started. If the antidepressant was requested by the patient or his family, and not by the nurses, you might find this information in the notes of the social worker, psychologist or primary care practitioner.
Implementing your nursing care plan is not enough. You must evaluate the effectiveness of your interventions. If they are not working, you can take further action. Then you’ll know you have provided the highest quality of nursing care possible.