At a certain point (designated intervals)you should evaluate the plan of care for the patient to see if it is working or not working. That is whether the patient has achieved the goals set in the beginning and if the goals were not achieved revise the plan of care to achieve the goals set. Example 1. 04 /12/21.Goal Met.
Chemotheraphy patient lost her hair( Alopecia) Educate patient about the wearing of hat or wig. After teaching, patient responded,I know that it will take a long time for my hair to grow back.Yes I understand that. I will be happy to try wigs and hats.She called her mother to get her some wigs and her husband to get her some hats.She sent pictures of the types of hats that she want to her husband.
Because patient has good self esteem, and demonstrated understanding of the teaching. The care plan does not have to be revised.She has demonstrated understanding of the teaching and disease process.
Philomena O,RN.
2. ANOTHER EXAMPLE:Delayed chronic wound healing. Wound is dark dry.Unhealthy wound.
04/30/21 Care plans will be : To prevent premature wound closure.
Obtain clean wound bed.Maintain moisture environment in the wound. Maintain healthy wound surroundings and wound edges and absorb excess exudate. Clean the wound as ordered by the doctor. Apply wound care dressing, obtain WOUNDCARE Consultation done. Antibiotics as ordered by the doctor.
Expected Outcomes: Wound is healing well as evidence by there is no signs of infection. No new skin breakdown. Wound has decreased in size after 2 to 4weeks. Patient and family members demonstrated understanding of the dressing change every day and where and when to get supplies. Will return in two weeks to the clinic for follow up appointment.
3. 05/24/21 DELAYED WOUND HEALING.
Patient went to the clinic for follow up appointment. Reevaluate plan of care to address if wound has healed after 2 to 4weeks.The wound is not healing. Size of wound did not decrease. There is evidence of infection as evidenced by smell huge amount of exudate drainage.Doctor orders patient to be readmitted.
Revised plan of care,antibiotics started intravenously.New dressing change ordered by the doctor. Wound consult ordered for evaluation and treatment. Will reevaluate in 2 to 4weeks.
Follow up with your facility policy and procedures. Send your comments below and for any clarifications.
Nurses You Move Me 