Assessing needs and planning care in nursing example 2025

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Assessment. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
Common nursing interventions include: Bedside care and assistance. Administration of medication. Postpartum support. Feeding assistance. Monitoring of vitals and recovery progress.
Step 3: Planning It involves selecting nursing interventions to implement, setting goals, and outlining implications and expected outcomes. Example: After selecting a nursing diagnosis (ineffective peripheral tissue perfusion), the nurse creates a care plan.
Assessment findings that include current vital signs, lab values, changes in condition such as decreased output, cardiac rhythm, pain level, and mental status, as well as pertinent medical history with recommendations for care, are communicated to the provider by the nurse.
Registered nurses prioritise the needs of people when assessing and reviewing their mental, physical, cognitive, behavioural, social and spiritual needs. They use information obtained during assessments to identify the priorities and requirements for person-centred and evidence-based nursing interventions and support.
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Initial evaluation or the general survey may include: Stature. Overall health status. Body habitus. Personal hygiene, grooming. Skin condition such as signs of breakdown or chronic wounds. Breath and body odor. Overall mood and psychological state.
Nursing assessment involves collecting data from the patient and analysing the information to identify the patients needs, which are sometimes described as problems. The process of planning care employs different strategies to resolve the needs identified as part of an assessment.

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