-24
1 st
Ch
step:data
collection
patientsays)
↳subjective (whatthe
Assessment
↳objective
·Pt/caregiver report
medical/surgical
4-
H
thinking
-Nursing diagnosis
Critical
(whatis
import forpt)
-Validation (is itaccurate?)
Interpretation
-
Nursing diagnosis
of
current state
based on
patient
2nd Step: diagnosis
Critical
Medical
⑰
-
#Infection -> constant
thinking
diagnosis
vs
diagnosis
nursing
⑭
fluid
constantvs.
Human response
Altered LOC -> fluid
-Improve treatment 3.
Outcomes
·Diagnostic reasoning
-
Clinical
nursing judgement
Collecting data
·Analyzing
s
strengths
-
-Health
help
vulnerabilities
determine
priority
nursing diagnosis
2nd step:Planning
critical
-
thinking
Care plan
·Individualized
Goal/outcomes
·Multiple
-
diagnoses
prioritization
(maybe pain
4th
step:Implementation
Treatment
strategies
-
·
!"#"$"#"%"&"#"'"(
Interventions
Nurse driven
isn'ta
priority)
·
Interdisciplinary
for
Rationale
interventions
how to
perform
pres,
post
Final
care team
safely
intervention needs
Step:Evaluation
Treatment plan
Goal met? Notmet?
·
Critical
↳
-
thinking
reassess
interventions
-modify
-
·
change in
situation needs
Assessment
Parameters
(whatare you
going tobe able to look at)
Evidence based
Medical record
standard parts
-
yptsmedical record
Demographic page
-informed consent
-
-
admitting He
Physician orders
-Medication record
-Med
reconciliation
-nursing interdisciplinary
incidentreports (NO)
Narrative Documentation
completed
-
s/s
anytime something
of infection
-procedures done
-
-
-
-
is
at
bedside
In infiltrated
admission and
discharges
education
discharge preparation
-extubations
·
!"#"$"#"%"&"#"'"(
Whatdid
you find? It response
notes
of
out
norm
When
reporting
-name
-
!"#"$"#"%"&"#"'"(
include:
of provider
details
as
whatis
being reported