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evaluation (determine if goals/outcomes have been met) Manage/refer/contact/notify (managing the care on behalf of the patient or caregiver) Teach/educate/instruct/supervise (educating patient or caregiver) note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.Ĭare/perform/provide/assist (performing actual patient care).assess/monitor/evaluate/observe (to evaluate the patient's condition).they have the following overall effect on the problem: goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing.planning (write measurable goals/outcomes and nursing interventions) there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:.the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary.this information will usually be found immediately below the title of a nursing diagnosis. many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information.nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. you can purchase it directly from nanda.your instructors might have given it to you. there are a number of ways to acquire this information. it helps to have a book with nursing diagnosis reference information in it. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). use: - medical disease information/treatment/procedures/test reference websites.if this information is not known, then you need to research and find it. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has.data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians.assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease.assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology). When care planning you should follow the nursing process: you will also get help from other students there. Please post in the nursing student assistance forum ( ) where i can find your questions much faster.
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