Professional Documents
Culture Documents
Workshop
Assessment
Diagnosis
Planning
Implementation
Evaluation
Case Scenario
Mr. Jones complains his throat and mouth
Assessment
First step in determining health status
Gather information
Gather all the puzzle pieces to put
Comprehensive Data
Collection
Begins before you actually see the patient
Comprehensive Physical
Assessment
Vital signs
Height & weight
Review of systems (neurological/mental
Organizing Assessment
Data
Cluster data into groups according to a
Diagnosis
AssessmentCritical analysis of data
Identifying Nursing
Diagnosis
Common language for nurses
A clinical judgment about an individual, family
Diagnostic Reasoning
Apply critical thinking to problem
identification
Requires knowledge, skill, and
experience
Big Picture
Fundamental Principles of
Diagnostic Reasoning
Recognize diagnoses
Keep an open mind
Back up diagnosis with evidence
Intuition is a valuable tool for problem
identification
Independent thinker
Know your qualifications & limitations
Nursing Diagnosis
Actual or Potential problems identified
Actual: actual evidence of
Planning
Risk for Impaired skin integrity related to
immobility
Now restate the first clause in a statement
that describes improvement, control or
absence of problem
The patient will have no signs of skin
breakdown during hospital stay.
Outcome needs to be time related. ( state
time period to achieve goal)
Achieving Goals/Outcomes
Be realistic in setting goals. (look at overall
Determining Interventions
Nursing interventions are actions performed
Determining Interventions
Interventions will be collaborative, combining
Implementation
Putting your plan into action
Set priorities after report
Assess and reassess
Perform interventions
Chart client responses
Give report to next shift
Implementation of Nursing
Interventions
Describes a category of nursing
Types of Nursing
Interventions
Protocols: Written plan specifying the
Implementation Process
involves:
Reassessing the client
Reviewing and revising the existing
care plan
Organizing resources and care delivery
Evaluation
Evaluation of individual plan of care includes
Evaluation
Step of the nursing process that
Evaluation of Goal
Achievement
Measures and Sources: Assessment
nursing care.
Essentially a diagram of patient problems and
interventions
Ideas about patient problems and interventions
are the concepts to be diagrammed.
Enhances critical thinking and clinical
reasoning
Used to organize patient data, analyze
relationships, establish priorities
Theoretical Basis of
Concept Maps
Roots in education and psychology
Also known as mind maps, cognitive
maps
Concept mapping requires critical
thinking
New knowledge is built on preexisting
knowledge, new concepts are
integrated by identifying relationships
Relationships
Identifying Goals, Outcomes, &
Interventions
Evaluate patient responses