ASSESSMENT

ANALYSIS/DIAGNOSIS

PLANNING
IMPLEMENTATION
EVALUATION 

1. collecting objective data like phys exam, lab results as well as subjective like pt prescription hx, allergies, and pt family interviews;  Objective data should include verified OTCs, vitamins and herbs; whether pregnant or breastfeeding;  If pt tells you, it is objective.  I think.
1. INITIAL ASSESSMENT – when first seen, more thorough and creates a baseline; identifies problems

                                                               i.      IMPORTANT to determine conditions before admission, to shownotHospital Acquired b/c now (2008) hospital must pay!  GOOD!

2. ONGOING ASSESSMENT – compare to baseline; at each pt contact

                                                               i.      How is pt responding to tx

                                                             ii.      Collect objective like BP pulse, et and subjective like relief of sxs?

1. analysis of data to determine independent nursing actions (no need of dr order)

                                                               i.      North American Nursing Diagnoses Association (NANDA) standardized nsg dx terms and diagnostic categories e.g “Effective Therepeutic Regimen Management ” etc. 

                                                             ii.      Are others besides NANDA’s (lecture)

                                                            iii.      Must be specific and measurable

1. sets goals to address needs and diagnosis as well as the expected outcomes
1. EXPECTED OUTCOMES = direct statement of pt goal to be achieved, are patient centered; eg

                                                               i.      Pt will comply with drug regimen

                                                             ii.      Pt will understand regimen

2. Set interventions that will meet the expected outcomes

                                                               i.      Will explain importance of compliance

                                                             ii.      Will explain regimen

3. Also time to gather whatever equipment needed to provide interventions, e.g IV materials, needles, etc

1. of plan; perhaps administering (a) drug(s)
1. Once implemented, it must be reassessed for efficacy, and more diagnoses are made.  Regarding drug administration:

                                                               i.      EFFECTIVE THEREPEUTIC REGIMEN MANAGEMENT = pt is taking as prescribed

                                                             ii.      INEFFECTIVE THEREPEUTIC EGIMEN MNGMT – pt not eaking as directed, so nurse must figure out why and help; may be adv reaxtions, maybe cant afford drug, etc etc etc

                                                            iii.      DEFICIENT KNOWLEDGE – pt may not understand how to administer, or forgets; may lack knowledge of med and what is for, what rxs to look for; must determine what pt does not know in order to teach

                                                           iv.      NONCOMPLIANCE – pt refuses med, maybe side effects, etc

                                                             v.      ANXIETY – hard to educate if anxious, so listen to pt, anser all questions, id fears and help reduce anxiety

1. determination of effectiveness of interventions in meeting expected outcomes; have they been met?  If not, will need more interventions.  Questions to answer like “is pain gone?” “Is BP down?” “Are there adverse reactions to be reported?” etc