In: Nursing
In Nursing careplan Assesment is the first step.
In assessment there are two parts subjective and objective data.subjective data obtained through information ftom client's point of view(symptoms) it include feelings ,.perception, concerns.Where objective data obtained through observation , physical examination, laboratory testing by the health worker(signs).
eg:-subjective data
The client says that,
eg;-objective data
by nurse
Nursing diagnosis
There are mainly 3 parts in diagnosis section
eg:-Deficient fluid volume(diadnostic label) related to bleeding(related factor) as evidenced by physical examination(defining characteristics)
Nursing goals
Goals provide direction for planning intervention,it also serves a crieria for evaluvatng client progress.
eg:-the patient will maintain optimal gas exchange(patient with dyspnea).
Intervention
Nursing interventions are the activities that a nurse performs to achieve client goals.
eg:-provide a quite and calm environment to the client and comfortable position by using pillows.
Implementation
implementations are the part that treatment plan into effect.
eg:-provided dorsal recumbent position to the patient.
Goals
Met goals refers to the wellbeing of the patient by the effectiveness of intervention.
eg:- pateint is able to maintain optimal gas exchange.