The Client Experiencing Self-Care Deficits and Risk for Injury
CASE PRESENTATION
Mr. Magee was admitted yesterday with right-sided weakness. His medical diagnosis is cerebral vascular accident (CVA). He is 68 years of age and resides alone in the house on his farm where he and his wife lived for 40 years. She died last year. He reports that he is right-handed and has difficulty holding a fork.
ASSESSMENT
• ‘‘I can’t handle this milk carton with only one hand.’’
• ‘‘I do not like to use that walker. It gets in my way.’’
• Gait unsteady and shuffling
• Asymmetrical strength in arms and legs
• Unable to hold fork in right hand
NURSING DIAGNOSIS 1:Feeding self-care deficit related to weakness in right hand AEB inability to hold fork.
NOC:Client will be able to feed self independently.
NIC:Serve finger foods to promote independence.
EXPECTED OUTCOMES The client will:
1. Attend a teaching session on feeding himself with his left hand at 1000 on 2/12.
2. Practice using adaptive spoon at 1400 on 2/12.
3. Use adaptive spoon for meals beginning with breakfast on 2/13.
INTERVENTIONS/RATIONALES
1. Present a teaching session ‘‘Feeding oneself with the nondominant hand’’ at 1000 on 2/12. For clients recovering from illness and/or injury, information about adapting to limitations fosters independence.
2. Provide the client with four foods of differing textures, adaptive spoons, and apron for a practice session at 1400 on 2/12. Providing practice time reinforces skills learned and fosters an improved confidence level in the learner.
3. Notify the dietary department to include a left-hand adaptive spoon with breakfast tray on 2/13. Using adaptive devices provides safety and promotes independence.
4. Encourage client to feed self independently at each meal, beginning 2/13. Recognizing and commending success promotes positive self-esteem.
5. Assist client with food preparation and feeding as needed at each meal, beginning 2/12. Assistance preserves strength, avoids tiring the client, promotes safety, and decreases frustration as the client strives for independence.
EVALUATION
1. Goal met. Mr. Magee attended teaching session on 2/12, asked questions, and participated in the practice session.
2. Goal partially met. Mr. Magee practiced using a spoon in his left hand to feed himself oatmeal, soup, ice cream, and canned peaches on 2/12. Successful self-feeding with all foods except soup. Continue practice, reevaluate 2/19.
3. Goal partially met. On 2/13, fed self 75% of each meal, using adaptive spoon. Continue. Reevaluate on 2/15.
NURSING DIAGNOSIS 2:Risk for injury: fallsrelated to unsteady, shuffling gait.
NOC:Risk for fall will be decreased by environmental modifications.
NIC:Instruct client in fall prevention measures (e.g., handrails, grab bars, and shower mats).
(Continues)
KEY CONCEPTS
• Evaluation, the fifth step in the nursing process, involves determining whether client goals have been met, have been partially met, or have not been met.
• The purposes of evaluation are to determine the cli- ent’s progress or lack of progress toward achieve- ment of client objectives, to judge the efficiency of nursing actions in helping clients to achieve objec- tives, to determine the health care agency’s overall ability to deliver care in an effective and efficient manner, and to promote nursing accountability.
• Evaluation is based primarily on the skills of com- munication and observation.
• Evaluation is a mutual, ongoing process occurring among the nurse, client, family, and other health care providers.
• The effectiveness of nursing interventions is eval- uated by examination of goals and expected out- comes that provide direction for the plan of care and serve as standards by which the client’s progress is measured.
• Evaluation is an orderly process consisting of seven steps: establishing standards, collecting data related to the goals and expected outcomes, determining goal achievement, relating nursing actions to client
status, judging the value of nursing interventions in assisting clients to achieve goals and objectives, reas- sessing the client’s status, and modifying the plan of care if necessary.
• There is a relationship between quality management and evaluation. Evaluation is necessary in the provi- sion of quality care because it is the mechanism used by nurses in determining how to improve care.
• Structure evaluation judges a health care agency’s ability to provide the services offered to its client population.
• Process evaluation measures nursing actions by examining each phase of the nursing process to determine the effectiveness of the actions in helping clients meet expected outcomes and goals.
• Outcome evaluation compares the client’s current status with the expected outcomes and examines all direct care activities that affect the client’s status.
• A nursing audit can focus on implementation of the nursing process, client outcomes, or both in order to evaluate the quality of care provided.
• Peer evaluation (peer review) is the process by which professionals provide to their peers perform- ance appraisal feedback geared toward corrective action.
EXPECTED OUTCOMES The client will:
1. Participate in physical therapy evaluation of mobility strengths and weaknesses on 2/11 at 1100.
2. Attend a muscle-strengthening class on 2/12 at 1600.
3. Perform all strengthening exercises prescribed BID at 1000 and 1600, beginning 2/13.
INTERVENTIONS/RATIONALES
1. Request physical therapy consultation for appropriate assistive devices, strengthening exercises, and gait training on 2/11. Collaboration with other health care providers provides the best care for the client.
2. Escort client to muscle-strengthening class on 2/12 at 1600. Provides safety and support as the client begins to learn new skills.
3. Assigned caregiver will record each exercise, number of repetitions, and client response BID. Document- ing client progress toward the achievement of goals aids in outcome attainment and evaluation of care.
EVALUATION
1. Goal not met. Appointment not kept on 2/11. Dental emergency. Continue. Reevaluate 2/15.
2. Goal not met. Unable to evaluate on 2/12. Continue. Reevaluate on 2/15.
3. 2/15: Goal met. Client attended muscle-strengthening class and has performed exercises as prescribed two times each day.
NURSING CARE PLAN (Continued)
• Evaluation enhances professional nursing account- ability by providing a mechanism for assisting the nurse to define, explain, and measure the results of nursing actions.
• Evaluating the quality of care is a shared responsibil- ity among members of the health care team.
REVIEW QUESTIONS
1. Which of the following accurately describes the pur- poses of evaluation? Select all that apply.
a. Determine client progress toward achievement of expected outcomes.
b. Determine effectiveness of nursing care.
c. Establish client expected outcomes.
d. Establish priorities for nursing interventions.
e. Promote nursing accountability.
f. Write the plan of care, including specific measur- able goals.
2. Which of the following client statements are indica- tors of client strengths? Select all that apply.
a. ‘‘I don’t think that I’ll be able to stop smoking.’’
b. ‘‘I dropped out of school in the eighth grade to go to work.’’
c. ‘‘I have no relatives to bother me.’’
d. ‘‘My company pays for my health insurance.’’
e. ‘‘My family is willing to change their eating hab- its since I’m on a diet.’’
f. ‘‘My wife and I are both employed as school teachers.’’
3. In which of the following situations is the nurse per- forming evaluation?
a. Determining a client’s baseline temperature b. Developing expected client outcomes
c. Asking a client if pain is relieved after adminis- tration of analgesics
d. Writing an individualized plan of care for a client 4. Which of the following statements best describes
the evaluation of quality care?
a. Carried out to determine whether the client feels better
b. Determined after the project is completed c. Performed only by nursing
d. Shared responsibility of multidisciplinary team 5. Which of the following mechanisms is based on
honest confrontation and open communication?
a. Establishing standards b. Outcome evaluation c. Peer review
d. Structure evaluation
6. A nurse helps reposition a client who has difficulty breathing. Which of the following nursing actions, when performed after the intervention, demon- strates evaluation?
a. Arranging pillows behind the client’s back b. Changing the rate of flow for oxygen delivery c. Checking the client’s respiratory status d. Instructing the client on the importance of
mobility
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