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ASSESSMENT PHASE
- Data
Collection
- Organize
Data
- Validate
Data
- Document
Data
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Subjective Data also referred to as symptoms or covert data
Objective Data also referred to as signs or overt data, are
detectable by an observer
Primary source is the client
Secondary source is family or anyone else that is not the
client
Methods of Data Collection
Observing To
observe is to gather data by using the sense.
Interviewing Is a
planned communication or a conversation with purpose
Examining Is a
systematic data-collection method that uses observation (i.e., the senses of
sight, hearing, smell, and touch) to detect health problems.
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DIAGNOSIS PHASE
- Analyze
Data
- Identify
Health Problem
- Formulate
Diagnostic Statements
Diagnostic
Statements
Problem (P): statement of the client’s response.
Etiology (E): factors contributing
Signs and Symptoms (S): defining characteristics manifested by the client
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Types of Nursing Diagnosis
Actual diagnosis is a client problem that is present
at the time of the nursing assessment.
Risk nursing diagnosis is a clinical judgment that a problem
does not exist, but the presence of risk factors
Wellness diagnosis
Possible nursing diagnosis is one in which evidence about a
health problem is incomplete or unclear.
Syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses
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PLANNING PHASE
- Prioritize
problems
- Formulate
goals
- Select
actions
- Write
nursing orders
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Types of Planning
Initial planning, admission assessment.
Ongoing planning
Discharge planning:
M edications
E xercise
T reatment/therapy
H ygiene
O ut-patient follow up
D iet/nutrition
S exual activity/spirituality
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INTERVENTION /
IMPLEMENTATION
- Determining
needs for assistance
- Putting
into action the plan
- Supervising
delegated care
- Documenting
nursing activities
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Types of
Intervention
Independent
Dependent
Collaborative
Cognitive or
Intellectual Skills Such as analyzing the problem, problem solving, critical
thinking and making judgments regarding the patient's needs.
Interpersonal Skills
Which includes
therapeutic communication, active listening, conveying knowledge and
information, developing trust or rapport-building with the patient
Technical Skills Which includes knowledge and skills needed
to properly and safely done the procedure
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EVALUATION PHASE
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Collecting data
related to outcome
Comparing data
Drawing conclusion
Continuing,
modifying or terminating the
nursing care plan
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