1. ASSESSMENT
- Is the first step in nursing process. The nurse gathers
information about the patient’s health status through
observation, interviews, and physical examination. This
includes gathering information about the patient’s past
medical history, current condition and any symptoms
that experiencing.
- In this stage is also an opportunity for the nurse to
establish a rapport with the patient and build trust.
Example:
• Data Collection: gather the patient’s medical
history, including the duration of diabetes, current
medications, blood glucose levels, dietary habits,
and any symptoms like fatigue, frequent urination,
or vision problems.
• Observation: note the patient’s physical
appearance, such as weight, skin condition, and
signs of neuropathy.
• Interviews: talk to the patient about understanding
of diabetes management, lifestyle and any
challenges that they face.
, 2. DIAGNOSIS
- Analyzing the assessment data to identify the patient’s
problem, which are then formulated into nursing
diagnosis. The nurse must consider all aspects of the
patient’ health, including physical, psychological, and
social factors to make an accurate diagnosis. The nurse
uses critical-thinking and problem- solving skills to
determine the underlying cause of the patient’s
symptoms.
Example:
It is based on assessment, identify the patient’s problem.
• Ineffective health management related to lack of
knowledge about diabetes.
• Risk for unstable glucose levels related to irregular
dietary intake and medication adherence.
• Risk for infection related to impaired skin integrity.
3. PLANNING
- The nurse should involve the patient in the planning
process to ensure that the plan of care meets their needs
and preferences. This involves setting measurable and