A postoperative patient receives a stat dose of injection Pethidine intramuscularly. After one hour, the nurse checks on pain relief. Which step of the nursing process is the nurse using here?

1. A

   Evaluation

2. B

   Assessment

3. C

   Implementation

4. D

   Planning

Appeared in: Daman & Diu Staff Nurse - 2018

Explanation

• The correct step is Evaluation, which involves assessing the patient's response to a nursing intervention.
• In this case, the intervention was administering pain medication (Pethidine).
• The nurse's action of checking for pain relief after a set time is a direct measure of the medication's effectiveness and whether the desired outcome was achieved.
• This step is crucial for determining whether to continue, modify, or discontinue the plan of care.

Why Other Options Were Wrong

• Option B: Assessment is the initial phase of data collection. The nurse in the scenario is not gathering initial data but is re-assessing to determine the outcome of an intervention.
• Option C: Implementation is the 'doing' phase, where the nurse carries out the planned interventions.
• Option D: Planning involves setting goals and creating a care plan. This step occurs before the intervention is carried out.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Steps of the Nursing Process (ADPIE) in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• The nursing process is the foundation of professional nursing practice, ensuring that care is organized, individualized, and effective.
• Evaluation is a critical patient safety step. If an intervention is found to be ineffective (e.g., pain is not relieved), the nurse must act by re-assessing the patient and modifying the care plan, which may involve notifying the prescriber for a different intervention.
• What if? If during the evaluation, the patient stated their pain was worse and they felt nauseous, the nurse would re-enter the assessment phase. The nurse would assess the new symptom (nausea), check vital signs, and re-evaluate the pain. The plan would then be revised to manage both the unrelieved pain and the new side effect, likely after consulting the physician.

How to Approach the Question

• First, identify the key action described in the question stem: "the nurse checks on pain relief."
• Recall the five steps of the nursing process in order: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE).
• Analyze the context of the action. The check is happening after an intervention (giving Pethidine) has already been performed.
• Match the action to its purpose within the ADPIE framework. The purpose of checking the result of an intervention is to see if it worked and if the goal was met.
• This purpose directly aligns with the definition of the Evaluation step.
• Eliminate the other options: It's not Assessment (initial data gathering), not Implementation (the act of giving the shot), and not Planning (deciding to give the shot).

Concept Tested & Keywords

• Concept Tested: Steps of the Nursing Process (ADPIE)
• Stem keywords: postoperative patient, injection Pethidine, checks on pain relief, nursing process
• Lead-in keywords: Which step
• Clinical cues: "After one hour" - This time frame is crucial as it indicates a follow-up to an action.
• Clinical cues: "checks on pain relief" - This phrase describes the act of determining an outcome.

Question ID

QpEQcSs6-4TfV-ZcTjS7RD

Copy ID

Reference Book

E6 Pharmacology Nursing Lilley 11e Part 1 pp. 22-24, 12-14

E6 Nursing Fundamentals Potter Perry 12e Part 2 p. 55-57