Nursing evaluation is a process of judging the value of individual characteristics, that is, judging against certain standards, and individual characteristics are obtained through measurement or evaluation.
Evaluation is a planned and systematic activity to compare the patient's health status with the expected nursing goals. In the implementation of nursing procedures, the focus of evaluation is the patient's health status, and the responsibility of evaluation is borne by the responsible nurse. The following will introduce the content, basic methods and forms of this evaluation.
content
1 First of all, collect information, which includes the following aspects:
(1) Physical appearance and function;
By directly observing and consulting medical records, we can understand the changes of patients' appearance and function, and infer the relationship between these changes and nursing measures.
(2) Special symptoms and signs;
In the nursing plan, it is often one of the nursing goals to relieve or eliminate the symptoms and signs that basically affect the health status of patients. Whether these goals have been achieved can be evaluated by direct observation, conversation with patients and examination of medical records.
(3) knowledge;
Nursing determines the specialized knowledge that patients should acquire after health education.
The scope of knowledge acquisition includes: patients' understanding of the disease, self-control of symptoms and signs, drugs, diet, activities and sports, seeking support, potential complications, timely reporting the symptoms and signs of medical staff, and preventing the recurrence of the disease.
Knowledge-related nursing goals can be evaluated by talking to patients or written tests.
(4) Operating skills:
This evaluation is often done through direct observation, and nurses can compare the observed patient's operation with the behavior described in the goal. It should be noted that for inpatients, the equipment used for teaching and evaluation must be used by patients at home.
(5) Psychological and emotional aspects;
The general patient's psychology and emotions are indirectly reflected through his behavior. Nurses should pay attention to the information provided by other medical staff through informal conversation, medical record discussion, shift report, reading various observation records and directly observing the patient's expression, posture, tone and language information.
2. After collecting the information of patients' health status, nurses should list the patients' reactions after implementing nursing measures, and compare these reactions with the target to measure the target.
The degree of goal realization can be divided into three types, namely, the goal is completely realized; Partial realization of the goal; The goal was not achieved. Discuss and analyze the reasons why the goal was partially achieved or not, and review the nursing plan.
When reviewing the nursing plan, stop taking measures for the solved problems, but further estimate other problems that the patient may have and work out the next goal. If the problem still exists and the planned measures are appropriate, continue to implement the original plan. The original thought that there may be problems that can be eliminated shall be cancelled. Modify inappropriate contents in diagnosis, objectives and measures.