PROBLEM OF NURSING EVALUATION

FROM GROUP 7
 FOREWORD

Thank God we pray for the presence of Allah Almighty God, thanks to the grace and the help
is so MAKE THIS NURSING EVALUATION can be completed on time.

This paper is based on references from some books and internet media in hopes to be useful
and a guide for all readers.

Acknowledgments do not forget we tell as much as possible to all parties who have helped
smooth the preparation of this paper. May Allah swt reply all the good of you all.

We realize this paper is still a lot of mistakes and shortcomings, both in writing and
information contained in this paper, given the ability of the author, therefore with all
humility and open arms we expect criticism and constructive suggestions for the
improvement and perfection of papers this as a guide for this paper in the future can be
even better.

Finally, hopefully this material can be useful and be a contribution of thought to the needy,
especially for us so that the expected goal can be achieved, Amen ..

Baubau, October 20, 2017

 TABLE OF CONTENTS

FOREWORD………………………………………………………………………

TABLE OF CONTENTS………………………………………………………………………………..

CHAPTER I INTRODUCTION………………………………………………………………….

CHAPTER II STUDY OF THEORY ........................................................................... ..

Knowing the meaning of nursing evaluation

b. Knowing the nursing evaluation function

c. Knowing the evaluation criteria of nursing

d. Know the techniques of nursing evaluation

e. Know the nursing component

f.Knowing the type of keperawatn evaluation

CHAPTER III CLOSING………………………………………………………………………..

3.1 CONCLUSION

3.2 SUGGESTIONS

BIBLIOGRAPHY………………………………………………………………………..
 Chapter I

PRELIMINARY

1.1 Background

Evaluation is an intellectual act to complement the nursing process that indicates how far the
nursing diagnosis, the action plan, and its accomplishments have been achieved. The evaluation itself
is a deliberate and continuous activity involving patients, nurses and other health team members.

Evaluation in nursing is an activity in assessing predetermined nursing actions, to determine the

optimal fulfillment of client needs and measure outcomes of the nursing process.

The purpose of evaluation is to see the client's ability to achieve goals. This can be done by
establishing a relationship with the client based on the client's response to the action kep given so
that nurses can take decisions that can solve client problems.

1.2 Purpose

Knowing the meaning of nursing evaluation

b. Knowing the nursing evaluation function

c. Knowing the evaluation criteria of nursing

d. Know the techniques of nursing evaluation

e. Know the nursing component

f. Know the type of nursing evaluation

 CHAPTER II

DISCUSSION

A. Definition of Evaluation

Evaluation is an action to complete the nursing process that indicates how far the nursing diagnoses,
the action plan, and the accomplishments that have been achieved. The evaluation itself is a
deliberate and ongoing activity involving patients, nurses and other health team members.

According to Craven and Hirnle the evaluation is defined as a decision of the effectiveness of nursing
care between the basic goals of nursing clients that have been established with the response of client
behavior that appears.

Evaluation in nursing is an activity in assessing predetermined nursing actions, to determine the

optimal fulfillment of client needs and measure outcomes of the nursing process.

B. Evaluation Function

1. Determine the client's health development.

2. Assessing effectiveness, efficiency and productivity.

3. Assess the implementation of nursing care.

4. As feedback to improve quality.

5. Supporting accountability and responsibility.

C. Evaluation Criteria

1. Effectiveness: which identifies whether the desired goal achievement is optimal.

2. Efficiency: concerning whether the desired benefit is really useful or valuable from the public
program as a facility that can be sufficiently effective.

3. Responsiveness: which involves assessing whether the policy outcome satisfies a particular group's
needs / desires, preferences, or values on the utilization of a resource.

D. Evaluation Technique

1. Interview

Interviews are asking or making questions related to the problems faced by the client, also called
anamnesa. The interview took place to ask questions relating to the problems faced by the client and
is a planned communication.

The purpose of the interview is to obtain data on the client's health problems and nursing issues, as
well as to establish a relationship between the nurse and the client. In addition, the interview also
aims to help clients obtain information and participate in the identification of problems and goals of
nursing, as well as assisting nurses to determine further investigations during the study phase.

All nurse interactions with clients are based on communication. Nursing communication is a complex
process and requires the ability of communication and interaction skills. Nursing communication is
usually used to obtain a history of nursing. The term therapeutic communication is a technique that
seeks to bring clients and families to mind and feel. These techniques include both verbal and non-
verbal skills, empathy and high caring.

Verbal techniques include open or closed questions, exploring answers and validating client
responses. Non-verbal techniques include: active listening, silence, touch and eye contact. Active
listening is important in data collection, but it is also a difficult thing to learn. Interview /
communication stage:

a. Preparation.

Before engaging communication with the client, the nurse must prepare by reading the client's
status. Nurses are expected to have no prejudice to the client, as it will interfere in fostering trusting
relationships with clients.
If the client is not yet willing to communicate, the nurse must not force or give the client a chance
when they are capable. Sitting positions and techniques to be used in the interview should be
arranged in such a way as to facilitate the interview.

b. Opening or Introduction

The first step of the nurse in starting the interview is by introducing yourself: the name, the status,
the purpose of the interview, the time required and the factors that are the subject of the
conversation. The nurse needs to provide information to the client about the data collected and will
be stored where, how to save it and anyone who may know it.

c. Content / stage of work

During the work phase in the interview, the nurse focuses on the subject of a particular issue to be
known. Things that need to be considered :

1) The focus of the interview is the client

2) Listen attentively. Explain if necessary.

3) Inquire about the most perceived complaints by clients

4) Use a language that is easy to understand by the client

5) Use open and closed questions just in time

6) If need be silent, to give the opportunity to the client to express his feelings

7) A touch of taptic, if necessary and possible.

d. Termination

The nurse prepares for closing the interview. For that the client must know when the interview and
the purpose of the interview at the beginning of the introduction, so it is expected at the end of the
interview nurses and clients able to assess the success and can draw conclusions together. If
necessary, the nurse needs to make another appointment for the next appointment. Things to
consider in conducting interviews with clients are:

1) Accept the existence of the client as is

2) Provide an opportunity for the client to express his / her grievances / opinions freely

3) In conducting interviews should be able to ensure a sense of security and comfort for the client

4) Nurses should be calm, polite and attentive

5) Using a language that is easy to understand

6) Not patronizing
7) Pay attention to the message delivered

8) Reduce obstacles

9) Appropriate sitting position (opposite, precise distance, way of sitting)

10) Avoid any interruptions

11) Listening is full of feelings

12) Provide a break opportunity to the client

2. Observation / observation

Observation is to observe the behavior and circumstances of clients to obtain data on client health
and nursing issues. Observation is done by using vision and other sensory devices, through touch,
touch and hearing. The purpose of the observation is to collect data about the problems faced by the
client through sensitivity of the senses.

Things to consider in making observations are:

a. Not always the examination that we will do is explained in detail to the client (although
therapeutic communication remains to be done), because sometimes this can increase client anxiety
or obscure the data (data obtained becomes impure). For example: "Sir, I will count your father's
breath in one minute". Most likely the data obtained becomes invalid, because the possibility of the
client will attempt to regulate his breath.

b. Concerning the physical, mental, social and spiritual aspects of the client

c. The results are recorded in nursing records, so they can be read and understood by other nurses.

3. Documentation Study

E. Evaluation Components

The evaluation component can be divided into 5 components (Pinnell and Meneses, 1986, pp. 229-
230):

1. Determine criteria, practice standards, and evaluative questions.

a. Criteria

The criteria are used as the observation guidelines for data collectors and as the determination of
the validity of collected data. All criteria used in the evaluation phase are written as outcome criteria.
The results criterion indicates the end of nursing care. While the nursing standard is used as a basis
for the evaluation of nursing practice widely. The result criteria is defined as a dock to explain the
response or outcome of the nursing care plan. The results will explain how the client's situation after
the observation.

The result criterion is expressed in terms of behavior as mentioned in the previous chapter, so that it
can be observed or measured and then explained in easy-to-understand terms. Ideally, each result
can be understood by everyone involved in the evaluation.

b. Standard Practices

Nursing care standards can be used to widely evaluate nursing practice. The standard states what to
do and can be used as a model for service quality. Standards should be based on research results,
theoretical concepts, and acceptable by current nursing clinical practice. Standards should be
carefully developed and tested to determine their suitability in use. Examples of standard usage can
be seen in the Nursing practice standard developed by ANA.

c. Evaluative Questions

To determine a criterion and standard, it is necessary to use evaluative (evaluative questions)

questions as a basis for evaluating the quality of nursing care and the client's response to
intervention. Questions that can be used to evaluate:

1) Assessment: is it possible to review clients?

2) Diagnosis: is the diagnosis prepared with the client?

3) Planning: has the goals been identified in the planning?

4) Implementation: does the client know about the intervention to be provided?

5) Evaluation: is nursing care modification necessary?

2. Collecting data on the new client's health status.

At this stage we need to consider some questions. Who is responsible for data collection? When is
the data obtained? And what means will be used to obtain data?

The professional nurse who first examines the client data and develops the plan is the person
responsible for evaluating the client's response to the intervention provided. Other nurses who help
provide intervention to clients should participate in the evaluation process. The validity of
information increases if more than one person participates in the evaluation.

3. Analyze and compare data against criteria and standards.

Nurses are skilled in critical thinking, problem-solving skills, and clinical decision-making abilities. This
ability is necessary to determine the suitability and importance of a data by comparing evaluation
data with criteria and standards and adjusting nursing care provided with existing criteria and
standards. At this stage nurses are required to be able to identify factors that may affect the
effectiveness of nursing care.

4. Summarize the results and make a conclusion.

The first thing that nurses need to do at this stage is to summarize the effectiveness of all the
interventions that have been implemented. Then put a conclusion on each diagnosis that has been
done intervention. The thing to remember here is that it is impossible to make a 100% successful
plan and therefore require an improvement and change-change, otherwise it is unlikely that the plan
has been compiled 100% failed. For that it takes carefulness in planning, appropriate intervention,
and assess the client's response after intervention as objectively as possible.

5. Implement appropriate interventions based on conclusions.

At this stage the nurse intervenes based on the results of the improved conclusions of re-planning,
objectives, outcome criteria, and plans for nursing care. Although the study is conducted regularly
and continuously, special aspects need to be reviewed and the addition of data for the accuracy of a
nursing care.

F. Type of Evaluation

1. Formative evaluation (process)

A focus on process evaluation (formative) is the activity of the nursing process and the quality of
nursing care. Process evaluation should be implemented immediately after nursing planning is
implemented to help assess the effectiveness of the intervention. Process evaluation must be
continuously implemented until the specified objectives are achieved. Methods of data collection in
process evaluation consisted of analysis of nursing care plan, group meeting, interview, client
observation, and use evaluation form. Written on care note. Example: help patient sit semifowler,
patient can sit for 30 minutes without dizzy.

2. Summary Evaluation (outcome)

Recapitulation and conclusions from observation and analysis of health status over time on purpose.
Written on progress note. Focus evaluation of results (sumatif) is a change in behavior or health
status of clients at the end of nursing care. This type of evaluation is carried out at the end of nursing
care in plenary.

G. Evaluation Results

1. Goal achieved / problem resolved: if client shows changes according to predefined standards.
2. Partially achieved / partially resolved objectives: if the client represents a partial change of
predefined standards and criteria

3. Objectives not achieved / problem not resolved: if the client does not show changes and progress
at all and even new problems arise

The problem determination is resolved, partially resolved, or not resolved is by comparing between
SOAP / SOAPIER with the objectives and predefined result criteria.

S (Subjective): is information in the form of a phrase obtained from the client after the action is
given.

O (Objective): is information obtained in the form of observations, assessments, measurements

made by the nurse after the action is done.

A (Analysis): is to compare between subjective and objective information with purpose and result
criteria, then taken the conclusion that problem solved, resolved sebahagian, or not resolved.

P (Planning): is an advanced nursing plan that will be done based on the analysis.

Example: medical dx: cough with secret purulent production

dx nursing: Ineffective airway clearance b.d excessive secret production

implementation: 1. Monitoring respiratory status

2. Encourage patients to drink warm water

3. Collaborate with a mucolytic doctor

4. Conduct chest physiotherapy: postural drainage and claaping

5. Teach effective cough

6. Examine the characteristics of the secret: consistency, quantity, color, and smell

7. Collaborate on the laboratory's secret inspection

evaluation: S: the patient said he was more able to breathe but still feel heavy when breathing

O: k / u well, RR 20x / i, still using respiratory auxiliary muscles, purulent secret dg

production ± 4 ml foamy green color and smelly

A: partially resolved issues

P: Continue interventions no 1,2,4, and 6

 CHAPTER III

COVER

A. Conclusion

From this paper, we can draw the conclusion that in the nursing process there is a final process called
the evaluation process, where this process is very important and influential on the outcome of the
nursing process, so that we as nursing students are aware of the sequences of the evaluation stage.

The evaluation stage is focused on the objective of the evaluation itself that is to guarantee the
nursing care optimally and to improve the nursing care so that the students after reading this paper
are expected to improve and know from the evaluation stage itself. Evalution is the process of
achieving objectives assessment and review of the nursing plan ./ Evaluation is an intellectual activity
to complement the nursing process that indicates how far the nursing diagnosis is, the successful
action plan has been successfully achieved.

Evaluation is the last stage of the nursing process, but it does not stop here. Evaluation only shows
which problems have been solved and which need to be reviewed, re-planned, re-implemented and
re-evaluated, so the nursing process is a continuous dynamic cycle.

B. Suggestions

After reading this paper, it is hoped that there will be criticism and suggestions that can build so that
we can perfect our paper.
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Nurjanah, Intansari.2010.Nursing Process NANDA, NOC & NIC.Jogjakarta: MocoMedia

Nursalam.2008.Process and Documentation of Nursing Concepts and Practices.Jakarta: Salemba

Medika

Nursalam, 2009, Process and Documentation of Nursing, Jakarta: s alemba Medika

Drs.Nasrul Effendi, 1995, Introduction to the Nursing Process, Jakarta: EGC

H.Lismidar, et al, 2002, Keperawatn Process, Jakarta: Publisher University of Indonesia

H.Zaidin Ali, MBA, MM, 2009, Nursing Documentation Basics, Jakarta: EGC