nursing care plans and predicting complications
NOTICING: Assessment: Client Data (What subjective and objective data from your client assessment indicates that the NANDA Label is a problem?)
INTERPRETING: Nursing Diagnosis Statement
(NANDA Approved)
Subjective Data: (What did the client say about the issue?)
NANDA Label:
Priority According to Maslow:
(circle one)
HIGH
MEDIUM
LOW
Definition:
Objective Data: ( What information, [lab values, vital signs, etc.} do you have about the issue?)
Lab / Diagnostic Values Pertinent to Problem:
Related to: (Etiology: Identify one. This is what you will develop the outcome to address.)
As Manifested by: (These are the signs and/or symptoms that prove the NANDA Label is a problem.)
INTERPRETING: Planning: Client Outcome:
Outcome (Only ONE behavior/response. Needs to be specific, observable, measureable, achievable, realistic and timed for THIS client. Individualize based on the client. DO NOT directly copy from the text.)
Time (When you expect the response to occur. If there is an agency policy for reassessment, such as with pain, utilize that time frame in your outcome to add it to your workflow.)
The client will
INTERPRETING: Planning: Interventions (Select interventions that help the client achieve the outcome. Do not choose all assess and monitor interventions. The majority of your interventions should reflect nursing action (actually doing something). INDIVIDUALIZE THE INTERVENTIONS FOR THIS CLIENT. Rationales for actions must be included. References for rationales must be in APA format.)
RESPONDING: Implementation: (Document how you implemented the intervention and the client’s response. If you were unable to implement the intervention, state that, and why.)
REFLECTING: Reflection-ON-Action; Reflection-IN-Action: (EVALUATION): (Documented in a Nurse’s Note)
What implementation note demonstrates the client met the outcome?
Nursing Process Form – Semester 1 (SP 2020)
CCST/ccst Page of
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