ASSESSMENT
Purpose
To gather, verify, and communicate data about client so data base is established
Key Actions
Collect nursing health history.Perform physical examination.Collect laboratory data.
DIAGNOSIS
Purpose
To identify health care needs of client; to formulate nursing diagnoses
Key Actions
Interpret data, including data validation and clustering.Formulate nursing diagnoses (see NANDA Approved Nursing Diagnosis)
PLANNING
Purpose
To identify client goals; to determine priorities of care; to design nursing strategies to achieve expected outcomes of care; to determine outcome criteria- SMART – goal should be Specific, Measurable, Attainable and Realistically Time-bound.
Key Actions
Identify expected outcomes.Select nursing actions.Delegate actions.Consult.Write nursing care plan.Ex. To reduce fever within the baseline data of 35.5 by giving prn antipyretic medication and performing tepid sponge bath for 4 hrs.
IMPLEMENTATION
Purpose
To complete nursing actions necessary for accomplishing plan Reassess client.
Key Actions
Review and modify existing care plan.Perform nursing actions.
EVALUATION
Purpose
To determine extent to which expected outcomes have been achieved. Very important to DOCUMENT your action! This is very essential for legal matters.
Key Actions
Establish evaluation criteria. Compare client response to outcome criteria. Analyze reasons for result and conclusions. Modify care plan.
Purpose
To gather, verify, and communicate data about client so data base is established
Key Actions
Collect nursing health history.Perform physical examination.Collect laboratory data.
DIAGNOSIS
Purpose
To identify health care needs of client; to formulate nursing diagnoses
Key Actions
Interpret data, including data validation and clustering.Formulate nursing diagnoses (see NANDA Approved Nursing Diagnosis)
PLANNING
Purpose
To identify client goals; to determine priorities of care; to design nursing strategies to achieve expected outcomes of care; to determine outcome criteria- SMART – goal should be Specific, Measurable, Attainable and Realistically Time-bound.
Key Actions
Identify expected outcomes.Select nursing actions.Delegate actions.Consult.Write nursing care plan.Ex. To reduce fever within the baseline data of 35.5 by giving prn antipyretic medication and performing tepid sponge bath for 4 hrs.
IMPLEMENTATION
Purpose
To complete nursing actions necessary for accomplishing plan Reassess client.
Key Actions
Review and modify existing care plan.Perform nursing actions.
EVALUATION
Purpose
To determine extent to which expected outcomes have been achieved. Very important to DOCUMENT your action! This is very essential for legal matters.
Key Actions
Establish evaluation criteria. Compare client response to outcome criteria. Analyze reasons for result and conclusions. Modify care plan.
