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									By: Donna Hess RN, MS
  Purpose: To establish a database about the client’s
   health, illness and ability to manage healthcare
 Nursing Activities: Collect & Sort Data
1.   Collect and Update
     -obtain history
     -conduct physical assessment
     -review client records
     -review nursing literature
     -consult support persons
     -consult health professionals
2.   Organize Data
3.   Validate Data
4.   Communicate – Document Data
    Purpose: To identify client strengths and problems
     (health) that can be prevented or resolved by
     collaborative and independent nursing
     interventions. To analyze and synthesize data to
     develop a list of nursing diagnosis and
     collaborative problems.
    Nursing Activities: Interpret & Analyze Data
1.    Compare data with standards
2.    Cluster or group data
3.    Identify gaps and inconsistencies in data
4.    Determine client’s strengths, risk & problems
5.    Formulate nursing diagnosis & document on Plan of Care
    Purpose: To develop an individualized plan of care that
     has specific goals/desired outcomes and related
     nursing interventions to reach the goals/outcomes.
    Nursing Activities: Goals, Outcomes & Strategies
1.    Set priorities & goals/outcomes with client involvement
2.    Write goals/outcomes
3.    Select nursing strategies/interventions (determine how to
      prevent, reduce, & resolve client problems)
4.    Consult with other health care professionals
5.    Write nursing orders & nursing care plan (including review of
      MD orders)
6.    Communicate nursing care plan to healthcare providers
      involved in the client’s care
    Purpose: To assist the client to meet desired
     goals/outcomes, promote wellness, prevent illness
     & disease, restore health, and assisting in client
    Nursing Activities: Initiate Plan of Care
1.    Determine the client’s need for assistance
2.    Perform or delegate planned nursing interventions
3.    Communicate nursing actions & plan of care
4.    Document care & client responses to care
5.    Reassess the client to update the database & plan of care
    Purpose: To determine whether to continue,
     modify (change) or terminate the plan of care.
     Measure goals/outcomes to see if they have been
     achieved and identify factors that positively or
     negatively influence the goals.
    Nursing Activities: Reassess
1.    Determine if goals/outcomes have been achieved
2.    Collaborate with client & collect data related to set goals
3.    Relate nursing actions to client outcomes
4.    Make decisions about status of problems (nursing
5.    Review and modify the plan of care & document
      achievement of modified plan of care

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