Analysis of Data
In this section the student needs an extra sheet of paper to initially write down her/his analysis to the data
collected in the assessment. This includes the assessment, lab, x-ray, physical therapy, dietary, or other
departments. The analysis should include:
List out abnormal and pertinent normal data
Identify and list the patient/family strengths
Cluster the data together, this will allow you to infer and identify problems List all
nursing diagnosis
Check the nursing diagnosis for the defining characteristics
If the defining characteristic are present, then the diagnosis exists
If the defining characteristic are not present, then continue to assess
List all Collaborative problems
Should be reflected in the medical diagnosis
List all referrals
Plan
Utilizing the lists created in the analysis, develop goals to each nursing diagnosis, collaborative problem
and referral. Remember that the goal needs to have measurable outcome criteria that will resolve the problem.
Then actions/interventions need to be developed that will monitor/evaluate the problem, directly resolve the
problem, or is directly involved in the resolution or maintenance of the problem.
Implementation/Evaluation
This area is were you try to actions that you stated would be used and to evaluate if the actions
worked. This will include assessment skills to evaluate and basic nursing skills to safely and effectively
implement actions on patients.