Phase 1: Recognize cues

Phase 1: Recognize cues (assessment)

Definition: The filtering of information from different sources (i.e., signs, symptoms, health history, environment)

IN OTHER WORDS

The nurse collects relevant information about the client.

NURSING ACTIONS (Expected responses and behaviors)

• Use knowledge, experience, and evidence to assess clients. • Collect relevant subjective/objective client information and data. • Identify subtle and apparent changes in client condition and related factors. • Document expected and unexpected patterns/trends/changes in clinical findings using verbal, nonverbal, written, and electronic modes of communication. • Recognize when to seek guidance from more experienced colleagues.