1. Nursing Diagnoses
1.1. Based on the Analyzed data
1.1.1. Determine risks and strengths
1.1.2. Identify the health problem
1.1.2.1. Prioritize the problems
1.1.3. Formulate diagnostic statement
1.1.3.1. Write a statement of problem or strength
1.1.3.1.1. Not a Medical diagnosis
1.1.3.2. Types of Nursing diagnose
1.1.3.2.1. An actual Diagnose
1.1.3.2.2. A "risk" nurse diagnose "Potential Nursing diagnosis"
1.1.3.2.3. Collaborative Problems "Potential Problems"
1.1.3.3. Components of Nursing Diagnose
1.1.3.3.1. The problem statement
1.1.3.3.2. The etiology ( related to R/T)
1.1.3.3.3. The definng characteristics
2. Planing
2.1. Establish a goal and expected outcomes, come from NANDA
2.1.1. Subject
2.1.1.1. Who is expected to achieve the goal?
2.1.2. General behavior that is desired
2.1.2.1. What actions must the person do to achieve those Goals
2.1.3. Time Frame
2.1.3.1. When is the person expected to perform the action
2.1.4. Specified Modifiers (indicators)
2.1.4.1. Under what circunstances is the person to perform the actions
2.1.4.2. How well is the person to perform?
2.2. Types of Planing
2.2.1. Initial Planning
2.2.2. Ongoing Planing
2.2.3. Dischage PLan
3. Implementation
3.1. Priorities
3.1.1. Maintaining ABC's Top Priority
3.2. Types of Nursing Implementations
3.2.1. Independent
3.2.2. Dependent
3.2.3. Collaborative
3.3. Consider the consequences
3.3.1. Safety
3.3.2. Resources
3.3.3. Pt's Values and beliefs
3.3.4. Other Therapies
3.3.5. Based on Nursing knowledge and research
3.3.6. Within standards of care stablished by state Law
4. Evaluation
4.1. Ongoing Evaluation
4.1.1. Collect Data
4.1.1.1. Compare Data
4.1.2. Determine
4.1.2.1. Was the goals/outcomes met?
4.1.2.1.1. The Goal was completely met
4.1.2.2. If so to what extend?
4.1.2.2.1. The goal was partially met.
4.1.2.3. The goal was not met
4.1.2.3.1. A new Carer plan has to be written
4.2. Intermittent Evaluation
4.2.1. Specific in tervals
4.2.2. Shows progress towards the Goal
4.3. Terminal Evalution
4.3.1. Patients conditions at the time of discharge
4.3.1.1. The goal was met AEB can expectorate sputum& his lungs have had normal breath sounds during postoperative period.
5. Phase I
5.1. I
5.1.1. Assessment
5.1.1.1. Collecting Data
5.1.1.1.1. Gather information about the patients health status.
5.1.1.2. Organizing Data
5.1.1.2.1. To obtain data systematically the nurse use an organized assessment framework.
5.1.1.2.2. Also referred t as nursing assessment
5.1.1.3. Validate Data
5.1.1.3.1. Double check
5.1.1.3.2. Verify
5.1.1.3.3. Confirm the data is accurate and factual
5.1.1.4. Recording Data
5.1.1.4.1. In order to complete the assessment phase
5.1.1.5. New Topic