Oct 14, 2007, 12:05 am
Being a student RN myself (just finished 2nd yr) I can see where you are coming from so here is my slant on it plus a working example.
Assessment: What have you found subjectively and objectively.
Planning: What do you intend to do and also are other members of the multidisciplinary team going to be involved.
Implementation: The needs you have identified and planned care around now need to be carried out.
Evaluation: Involves observing, documenting and measuring. It compares actual results with what was expected to happen. Was the intervention successful? or Does the intervention need to be refined to provide a better outcome.
Eg: Elderly post op patient that is now stable needs to be encouraged to deep breath to prevent post op actelectasis.
Diagnosis: Risk of ineffective airway clearance as a result of postoperative atelectasis due to surgery as manifested by shallow breathing.
Assessment: Patient shallow breathing and oxygen saturation not at pre op level.
Planning: Educate patient on the use of incentive spirometry and coughing techniques. Adjust bed to facilitate ease of breathing. Maintain routine observations. Incorporate the physiotherapist in care plan by evaluating patient for ambulation.
Implementation: Instructed patient to use incentive spirometry every hour and observed technique. Bed raised to high fowlers positon. Observations carried out hourly. Physiotherapist assisted with first ambulation post op and has given instructions for patient to sit in chair for meals if pain tolerable.
Evaluation: Patient using incentive spirometry and coughing as instructed. Oxygen saturation has returned to pre op level. Patient able to ambulate with assistance and sit in chair for meals with minimal pain levels.
Not an ideal scenario but I hope it helps.
Cheers.
