NURSING PROCESS TEMPLATE:
| Assessment (Recognizing Cues) Which client information is relevant? What client data is most important? Which client information is of immediate concern? Consider signs and symptoms, lab work, client statements, H & P, and others. Consider subjective and objective data. | |
| Analysis (Analyzing Cues) Which client conditions are consistent with the cues? Do the cues support a particular client 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 serious explanation? What is the priority order for safe and effective care? In order of priority, identify the top 3 client conditions. | |
| 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 client’s care outlook or status improve? |
Client Information (SBAR, H&P)
Main Concept
(Should be focus of below map)
CONCEPT MAP TEMPLATE:
Recognizing Cues (S&S) Disease Process/Pathophysiology/Risk Factors
Analyzing Cues/Conditions Prioritizing Hypotheses
Generate Solutions/Outcomes/Interventions Taking Action – (How To)
SMART Planning
Evaluating Outcomes