A= assessment data
D= nursing diagnosis
P= plan
I= implementation of care
E= evaluation of care
*includes things we observe ask both subjective and objective
*head to toe assessment
*signs and symptoms the patient has like fevers, V/S, pain
*comprehensive and admission assessment data
*information the patient or their family tell you
*other healthcare worker's documentation about the patient as they are caring for them such as occupational therapy, physicians, physical therapy, RT
types of assessment
Comprehensive or Admission Data Base:
*usually on admission to the hospital or the unit
*interviewing: preparatory, introduction, working, termination
*looking at a specific problem like for specific body systems
*what is happening right now!
Nursing Diagnosis
1. this is different than the doctor's diagnosis
2. it reflects what have noticed needs attention for your patient
3. it is a NANDA approved diagnosis. We do not make up our own diagnosis! These diagnosis are available in your nursing process book, care plan book etc
4. it is something NURSES can fix without the doctor's order
5. we think about our patient's strengths and weaknesses
6. we do take into account the doctor's diagnosis as well as what treatment orders the doctor has given us in the patient chart. We look at information collaboratively from other health care workers taking care of our patient
What is unhealthy about patient?
What causes the patient to have this unhealthy state?
defining characteristics
What is the subjective or objective data that tells you there is a problem?
*What are you going to do with this patient?
*You know all their vital signs, you know what you found out during your head to toe assessment. You know what the doctor and other health care workers say about the patient. You know what treatment orders the doctor ordered.
*now ....what does my patient need while I am taking care of them during this shift? Not just what the doctor says, but what I can see based on my nursing diagnosis. Sometimes we plan weeks or montsh in advance
*I know what is going on and now i have to decide how i will solve the problem that I can solve without the doctor telling me to do so
*I will plan that I can solve it and start listing out the things I can do. I will plan that I can get it done by a certain time frame. I let others know what my plan is.
Cognitive Outcomes
tell about the patient's knowledge or intellectual behaviors
Psychomotor Outcomes
tell us about the patient's achievements in a new skill
Affective Outcomes
tell us about the patient's values, beliefs, attitudes and any changes
Physiological Outcomes
tell us about physical changes happening to the patient
Outcomes are:
1. written in terms of the patients response
2. are the opposite of the problem
3. relate to only one nursing diagnosis
4. based on problems and not etiologies
5. may have more than one goal
6. are measurable
7. have a target time
PLAN interventions consist of things we can:
*monitor actions the nurse can take, teaching the patient or family members, referrals to other health care providers
*it includes initial planning, ongoing planning and discharge planning
*we call these plans: Kardexes, Plan of Care, Care Plans, Care Maps, Clinical Pathways, and Discharge plans
5 rights of delegation
1. right task
2. right circumstances
3. right person
4. right direction/communication
5. right supervision
Begin doing what I said I would do.
I will state that I am doing it in my plan of care or care plan
1. did my plan work?
2. did my patient achieve the goals/outcomes?
3. do I need to revise the plans?
4. Should I re-evaluate the patient's assessment?
5. has something changed about my patient?
6. time to reassess
7. or terminate care