Problem
Patient had a stroke, 65 years old Male, heavy smokey, history of hypertension, COPD, and hadtype 2 diabetes. Left side paralysis both lower and upper extremities. 265 pouns
NURSING PROCESS TEMPLATE:
Assessment (Recognizing Cues)
Which patient information is relevant? What patient data is most important? Which patient information is of immediate concern? Considersigns and symptoms, lab work, patient statements, H & P, and others. Consider subjective and objective data.
Analysis (Analyzing Cues)
Which patient conditions are consistent with the cues? Do the cues support a particular patient condition? What cues are a cause for concern? What other information would help to establish the significance of a cue?
Analysis (Prioritizing Hypotheses)
What explanations are most likely? What is the most seriousexplanation? What is the priority order for safe and effective care?
Planning (Generate Solutions)
What are the desirable outcomes? What interventions can achieve these outcomes? What should be avoided? (SMART Planning- specific, measurable, attainable, realistic/relevant,time-restricted- Goal setting)
Implementation (Take actions)
How should the intervention or combination of interventions be performed, requested, communicated, taught, etc.? What are the priority interventions? (Mark with asterisk)
Evaluation (Evaluating Outcomes)
What signs point to improving/declining/unchanged status? What interventions were effective? Are there other interventions that could be more effective? Did the patient's care outlook or status improve?