Assessment and diagnosis

Topics: Nursing, Nursing care plan, Evaluation Pages: 3 (925 words) Published: January 29, 2014

Plan, Implement and Evaluation
Thama Bradshaw
ITT-Technical Institute


In the following document I will discuss Plan, implement, and evaluate components of the nursing process at length. I will define the plan, implement, and evaluation in the nursing care process. While showing how it is used in the nursing field.

Plan, Implement and Evaluation

The nursing process is an organizing framework for professional in the nursing practice. It is the critical thinking process for the nurse to utilize to give the best care possible to the client. It is very similar to the steps used in scientific reasoning and problem solving. Main components of the process include these steps of the nursing process known as ADPIE. A stands for assess which is performing a nursing assessment. D stands for diagnosis, P stands for the care plan, I stand for implementing the care plan and E stands for evaluating the outcome. In this following document I will go more in depth and discuss the last three steps. Let’s start with Planning. Planning in the nursing care plan involves identifying the priorities as well as determining the client specific outcomes and interventions. The nurse must determine the urgency of the identified problems and prioritize the patient needs. Nursing diagnoses should be prioritized first by immediate needs based on airway, breathing, and circulation. The highest priority can and should by determine by using the Maslow’s hierarchy of needs. In the Maslow’s hierarchy, priority is given to most severe problems that may be life threatening. The planning should be done, when possible with the client and their family to increase efforts and understanding. This also helps the compliance with the proposed plan and outcomes, which increase a positive result to the patients care. Writing a proposed plan and outcomes statement, it is best to make sure it is SMART, which means:...

References: Ackley, B. J. (2012). nursing diagnosis handbook. Missouri: wiley.
Jacob, C. (2014). Contemporay Nursing. Missouri: Elsevier.
T.O 'Toole, M. (2013). Mosby 's dictionary of medicine, nursing adn health professions. Missouri: Mosby.
To summarize the knowledge I have gain and discuss in this document about assessment and diagnosis in the nursing care process is to make sure you collect accurate information in the patient story. Also to gather information from family and to organize information from most important to least, to make the most appropriate diagnosis for the patient care. When diagnosis is made be sure to label the diagnosis accurately and to follow the NANDA-I guidelines in providing a proper diagnosis for the client. I hope this document have made you more aware on the assessment and diagnosis process in the nursing care plan and what it is define as and how it is used to provide care to patient in today’s world.
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