Data collection carried out in an organized, systematic way. Data is gathered to determine and eliminate or manage actual or potential health problems. The data is accurately recorded. Ways of helping patients obtain optimum wellness and independence are identified.
Requires analysis of data gathered during assessment, clustering related information, identifying problem areas, and choosing appropriate nursing diagnosis.
Involves determining specific desired outcomes for each nursing diagnosis. While planning interventions to achieve those outcomes, one considers ways to promote optimum wellness and independence. How to achieve the desired outcomes in the most timely, cost-effective way is decided.
Begun by preparing to perform the interventions. Equipment and supplies are gathered and procedures are thought through before beginning the,. Interventions are performed and responses to them are assessed. Changes in interventions are instituted as needed. Accurate documentaion of interventions and patient response occurs.
Carried out by gathering data to determine if expected outcomes have been achieved. When interventions are not achieving expected outcomes, reconsideration of what needs to be done occurs. Aspects of the plan of care are modified or terminated as appropriate.