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Nursing Process Diagnosis Plan Implementation Evaluation
Nursing Process Diagnosis Plan Implementation Evaluation
Nursing
Process:
Diagnosis
Nursing Diagnosis
Nursing Diagnosis
NURSING DIAGNOSIS:
the phase in
which a nurse
determines the
meaning of
assessment
data.
DIAGNOSING:
Risk
for
Wellness
Diagnostic
Reasoning:
Validation with...
Patient
or
significant
others
Validation with...
Other
professionals
Validation with...
Reference
sources
Diagnostic Statement:
1. The human response
(NANDA)
2. Related / risk factors
3. Patient response
Related Factors:
Physiological
Psychological
Sociocultural
Environmental
Spiritual
for falls
R/T side effects of
medications
aeb unsteady gait,
drowsiness.
role performance
R/T fear of death
aeb avoidance of wife and
other family members.
deficit
R/T language barrier
aeb unable to follow
medication regime as written,
cannot read & understand
English.
R/T conflict
between religious beliefs &
health regimen
aeb patient does not follow
dietary regime as prescribed.
evidenced by(aeb)
Objective data
Subjective data
Nursing Diagnosis
PLANNING
Development of
strategies to
reinforce
healthy patient
responses
PLANNING - Formal
conscious,
deliberate activity
involving
decision making,
critical thinking,
and creativity.
PLANNING: Informal
Exercise: Prioritize
Exercise: Prioritize
Exercise: Prioritize
2. GOALS: (Outcomes)
1. Must be
realistic
2. Of mutual
agreement
3. Measurable
PLANNING Writing
(Goals)
Outcomes
4. Derived from
nursing diagnosis
5. Provide
direction
imple/specific
easurable
cceptable/attainable
ealistic
imed
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PLANNING Interventions/
Characteristics of interventions:
1. Individualized
2. Developed with others
3. Reflect current nursing practice
4. Based on scientific rationale
5. Provides for continuity of care
Documentation
Planning Interventions:
The nurse will
Assessment
Nursing care
Pharmacologic
Nutrition
Diagnostics
Education
Referrals
PLAN OF CARE
INTERVENTIONS:
PLANNING - Documentation
Plan of care:
1. Written by an R.N.
2. Initiated following
first patient contact
3. Readily available
4. Current
IMPLEMENTATION:
PUTTING THE
PLAN INTO
ACTION AND
OBSERVING
INITIAL
RESPONSES.
Measurement
Criteria:
1. Utilizes evidence
based interventions
specific to
diagnosis
2. Implemented in a
safe and effective
manner.
3. Interventions are
documented.
IMPLEMENTATION - Stages
Preparation
Intervention
Documentation
1.
2.
3.
4.
5.
6.
7.
IMPLEMENTATION:
Interventions - The nurse will:
Assess
Provide Nursing Care
Administer medications
Provide nutrition
Evaluate diagnostic
findings
Instruct/Teach
Refer/Consult
EVALUATION:
EVALUATION Steps:
1. Identify criteria
and standards.
4. Document
findings
2. Data collection
5. Terminate,
continue or
modify.
3. Interpret
findings
Implementation/Evaluation
Implementation:
Doing,
Delegating,
Recording
Planning
Evaluation:
Of outcomes,
Care plan,
Nursing care
Assessment
Diagnosis
EVALUATION Modification
NURSING PROCESS
Cont.
5. Revising plan of care
6. Interviewing the client
7. Writing a nursing diagnosis
8. Outcomes achieved?
Cont.
9. Developing interventions to achieve
outcomes
10. Recording care given
11. Developing a plan of care
Typical Question:
Mr. S. was medicated for abdominal pain (8); one hour later
continued to complain of pain (6). The nurse called the
physician who ordered additional medication. Thirty minutes
after medicated the patient reported pain at (1). Based on your
understanding of the nursing process as responsive to the
changing needs of patients, allowing the nurse to move back
and forth using steps most appropriate to the clients needs,
which steps of the process were used by the nurse in caring for
this patient?
assessment, diagnosis, implementation
implementation, evaluation, modification
assessment, implementation, evaluation
all 5 steps
A.
B.
C.
D.
Myocardial infarction
Cardiac catherization
Abnormal blood gas levels
Increased airway secretions
A.
B.
C.
D.