Steps
Step 1
Case Selection and Nursing Assessment Framework Design
The core task of this step is to select a representative clinical case and design a systematic nursing assessment framework. The case should cover multiple body systems and demonstrate complete application of the nursing process.
• Select typical case: choose a case with multiple nursing problems from internal medicine, surgery, geriatrics, or community nursing (elderly hypertensive patient with diabetes, postoperative recovery patient, COPD patient); obtain complete history and examination data
• Design nursing assessment framework: based on Gordon's Functional Health Patterns or NANDA framework, design assessment covering 11 functional domains including general data, present illness, past history, physical assessment, psychosocial assessment, laboratory tests
• Develop assessment plan: determine assessment methods (interview, observation, physical examination, chart review), assessment tools (scales: pain scale, anxiety scale, pressure ulcer risk, fall risk), and assessment timeline
Deliverable: Case summary, nursing assessment framework table, assessment tool list, assessment implementation plan | Quality standard: Typical and appropriately complex case, systematic and comprehensive assessment framework, scientific and reasonable tool selection
Step 2
Systematic Nursing Assessment and Data Collection
The core task of this step is to conduct systematic and comprehensive nursing assessment according to the framework, collecting both subjective and objective data. It requires communication skills, physical assessment skills, and critical thinking.
• Conduct nursing interview and health history collection: use therapeutic communication skills; collect subjective data including general data, present illness, past history, medication history, allergies, family history, psychosocial history, lifestyle; protect patient privacy
• Perform physical assessment: following inspection, palpation, percussion, auscultation, olfaction order; conduct head-to-toe systematic examination; measure vital signs (temperature, pulse, respiration, blood pressure, SpO2); identify positive signs in each system; document all abnormal findings
• Collect objective data: review medical records for laboratory results (CBC, blood chemistry, urinalysis), imaging results (X-ray, CT, ultrasound), ECG; perform risk assessments using scales (Braden score, Morse Fall Scale, NRS pain score)
Deliverable: Complete nursing assessment form, physical assessment record, laboratory/imaging results summary, risk assessment scale scores | Quality standard: Complete and accurate assessment data, standardized physical examination, comprehensive abnormal finding identification, timely and clear documentation
Step 3
Nursing Diagnosis Establishment and Care Planning
The core task of this step is to analyze assessment data using critical thinking, establish nursing diagnoses, and develop a comprehensive care plan. Nursing diagnoses should follow NANDA-I standardized terminology including problem, etiology, and defining characteristics.
• Organize and analyze assessment data: categorize subjective and objective data; prioritize health problems using Maslow's hierarchy; identify abnormal data and risk factors; find meaningful nursing cues; form inferences and hypotheses
• Establish nursing diagnoses: following NANDA-I classification system, list at least 5 nursing diagnoses; each includes name, definition, defining characteristics (subjective + objective), related factors or risk factors; prioritize by high/medium/low priority
• Develop care plan: set short-term and long-term goals for each diagnosis (SMART: Specific, Measurable, Achievable, Relevant, Time-bound); formulate specific nursing interventions (observation, basic care, treatment collaboration, health education, psychological care); note rationale and frequency
Deliverable: Nursing diagnosis list (with defining characteristics and related factors), care plan table (goals, interventions, rationale, evaluation time), diagnosis prioritization rationale | Quality standard: Accurate and standardized nursing diagnoses, reasonable prioritization, specific and measurable goals, detailed and evidence-based interventions
Step 4
Nursing Intervention Implementation and Outcome Evaluation
The core task of this step is to implement nursing interventions according to the care plan and systematically evaluate nursing outcomes. Implementation requires technical skills, communication ability, and keen observation, with continuous reassessment and adjustment.
• Implement nursing interventions: execute nursing procedures according to care plan (vital sign monitoring, medication administration, wound care, dietary care, elimination care, positioning, health education, psychological care); strictly follow verification system and aseptic technique; record execution time and patient response
• Dynamic observation and documentation: use PIO format (Problem-Intervention-Outcome) for dynamic recording; assess patient condition change each shift; observe treatment effects and adverse reactions; promptly identify new nursing problems; adjust interventions
• Nursing outcome evaluation: at designated evaluation time points, compare actual patient health status with expected goals; determine if goals are fully met, partially met, or unmet; analyze reasons for unmet goals; revise care plan; reassess if necessary
Deliverable: Nursing implementation records (PIO notes), nursing outcome evaluation form, revised care plan, nursing summary | Quality standard: Nursing interventions fully implemented, standardized operations, timely and accurate documentation, objective and comprehensive outcome evaluation
Step 5
Nursing Record Writing and Holistic Nursing Summary
The core task of this step is to organize all nursing data, write a complete and standardized nursing record, and summarize the holistic nursing process with reflection. Nursing records are legally binding formal documents requiring standardized writing and objective content.
• Write complete nursing record: following nursing documentation standards, organize assessment forms, nursing diagnosis/problem list, care plan, nursing notes, health education records, discharge instructions; ensure standardized terminology, clear writing, accurate data
• Holistic nursing summary: systematically review the entire nursing process; summarize application experience of each nursing phase; analyze effectiveness of interventions; discuss difficulties and shortcomings; propose improvement measures; demonstrate evidence-based nursing thinking
• Case presentation preparation: create case presentation PPT including case introduction, nursing assessment, nursing diagnoses, care plan, interventions, outcome evaluation, nursing reflections; prepare 10-minute oral presentation with ability to answer questions
Deliverable: Complete nursing record (full set of nursing documents), holistic nursing summary report, case presentation PPT | Quality standard: Complete and standardized nursing record, in-depth reflection with insights, clear and professional presentation, holistic nursing philosophy demonstrated