Data gathered from sources other than the patient, such as family, healthcare records, and other members of the healthcare team.
To evaluate the effectiveness of the interventions provided and document the client’s response.
The Nursing Process is a systematic method that helps nurses make clinical judgments that are appropriate for clients.
Data gathered directly from the patient through methods such as interviewing, observing, and physical assessments.
Creating a plan to address the identified client problems.
The skill of analyzing and interpreting data to solve problems and achieve desired outcomes, including questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity.
Determining the client problems based on the collected data.
Clinical reasoning is the process of thinking critically and making decisions in nursing that improves with practice over time.
To determine and prioritize patient goals, develop expected outcomes, and write a Nursing Care Plan based on SMART criteria.
Objective data is overt, measurable, and detected by the senses, while subjective data is covert, based on feelings and sensations reported by the patient.
The outcome is the visible or observed result that considers nursing knowledge, client situations, and prioritization of client problems, while utilizing evidence-based practice.
Specific, Measurable, Attainable, Realistic, and Time-bound.
Vital signs, lab results, drainage, breath sounds, diaphoresis, and jaundice.
The mental process used to analyze data from a clinical situation to make decisions based on that analysis, requiring assessment, data compilation, and decision-making regarding client care.
Collecting subjective and objective data about the client and reporting changes to the RN.
Putting the interventions in action to assess the patient’s response to care/interventions and comparing actual patient outcomes to expected outcomes (SMART Goals).
Assessment, which involves collecting objective and subjective data about the client.
A model for understanding human behavior motivations, represented as a pyramid with levels including physiological needs, safety, love and belonging, esteem, and self-actualization.
Taking action to provide care as outlined in the planning phase.
To assess whether the patient has met the SMART goals set in the plan of care and to reexamine previous steps if outcomes are not successful.
Collaborating with the RN to take action as outlined in the planning phase.
A statement of actual or potential problems regarding a patient's health status, covering physical, developmental, intellectual, spiritual, emotional, and social dimensions, and must be derived from the NANDA list.
Creating a plan to address client problems under the supervision and guidance of the RN.
No, clinical reasoning and judgment cannot be delegated.
The phase where the nursing care plan is put into action through the actual administration of planned care.
Pain level, nausea, and dizziness, which are based on what the patient tells you.
