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30- A- pg 262 16-3 4 types of assessments: initial, problem focused, emergency, and time lapsed. Assessments vary according to their purpose, timing, time available, and client status. Assessments should include the clients perceived needs, health problems, related experience, health practices, values, and lifestyles. To be most useful the data collected should be relevant to a particular health problem. JCAHO requires every patient have an initial assessment of history and a physical performed and documented within 24 hours of admission as an inpatient/. Types of data can be subjective or objective. Sources of data can be primary or secondary. Client is primary. Methods used to collect data are observation, interviews, and examining. To complete the assessment phase the client’s data is recorded in a factual matter. Assessment must be complete and accurate because nursing diagnoses and interventions are based on this info.
D- 5 types of diagnosis: actual-client problem that is present at the time of the assessment and is based on the presence of associated signs and symptoms. Risk- clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. Wellness- describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement. Possible- one in which evidence about a health problem is incomplete or unclear. Requires more data either to support or to refute it. Syndrome- diagnosis associated with a cluster of other diagnoses.
Diagnosis has three components: the problem and its definition, the etiology, the defining characteristics.
P- Types of planning include the initial, ongoing, and discharge. Initial- the nurse who performs the admission assessment usually develops the initial comprehensive plan of care. Planning should be initiated right away, especially because of the trend towads shorter hospital stays. Ongoing- done by all nurses who work with the client? As nurses obtain new information and evaluate the clients responses to care they can individualized the initial care plan sooner.
Discharge- the process of anticipating and planning for needs and after discharge is a crucial part of comprehensive health care and should be addressed in each cleats care plan.

I- consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions. The nurse performs or delegates the nursing activities for the interventions that are developed in the planning step and then concludes the implementing phase by recording the interventions and the resulting client response. To implement a care plan successfully, nurses need cognitive, interpersonal and technical skills. Process of implementation on p 317 fig 19-1. the desired outcomes determine the data that must be collectd to evaluate the client’s health status. Before implementing an order, the nurse reassesses the client to be sure that the order is still appropriate.

E-determine the effectiveness of the interventions.