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Example: Mrs. G is a 54-year-old hairdresser who reports pressure over her left chest
“like an elephant sitting there,” which goes into her left neck and arm.

Objective Data
What you detect on the examination
All physical examination findings
Example: Mrs. G is an older white female, deconditioned, pleasant, and cooperative.
BP 160/80, HR 96 and regular, respiratory rate 24, afebrile.

Methods of assessment
 Nursing health history
 Physical assessment
 Diagnostic evaluation

Nursing Diagnosis
Diagnosis means reaching a definite conclusion regarding the patient’s strengths and
human responses. This diagnostic process is complex and utilizes aspects of intelligence,
thinking, and critical thinking.
The nursing diagnosis is a clinical judgment about individual, family, or community
responses to actual or potential health problems/life processes. Nursing diagnoses provide
the basis for the selection of nursing interventions to achieve outcomes for which the
nurse is accountable.
Nursing planning
Planning involves a series of steps in which the nurse and the client priorities problems
and stated goals or expected outcome to resolve or minimize the identified problems of
the client
Nursing implementation
Implementation refers to the action phase of the nursing process in which the nursing care
plan is put into action.
It is focused on resolving the patient’s nursing diagnoses and collaborative problems and
achieving expected outcomes, thus meeting the patient’s health needs.
Evaluation
Evaluation simply means assessing what progress has been made toward meeting the
expected outcomes; it is the most ignored phase of the nursing process.

General instruction for all procedures
 Wash your hands before and after every Procedure
 Prepare all Equipment necessary for the specific Procedure
 Explain the Procedure to the patient and get oral or written consent before you start

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