ASSESSMENT PHASE
Data
Collection
Organize
Data
Validate
Data
Document
Data
|
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.
|
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
|
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
.
|
PLANNING PHASE
Prioritize
problems
Formulate
goals
Select
actions
Write
nursing orders
|
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
|
INTERVENTION /
IMPLEMENTATION
Determining
needs for assistance
Putting
into action the plan
Supervising
delegated care
Documenting
nursing activities
|
Types of Intervention
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
|
EVALUATION PHASE
|
Collecting data
related to outcome
Comparing data
Drawing conclusion
Continuing, modifying
or terminating the nursing care plan
|
