Nursing Process
Nurses use this to identify & treat client problems.
Problem-solving approach.
A
Assessment. Foundation of nsg process.
Use client's S/S.
Analyze to form a judgement.
Based on clinical judgement & knowledge while also evidence-based.
Intervention. (Steps to achieve the client's goals.)
Holistic & detailed collection.
Client information.
Response to human problems, provide care, interventions for prevention.
Goals of the nsg process.
D
Diagnosis. Cluster data to formulate evaluative judgement regarding client health.
PES - 3-part system.
Problem (NANDA-approved nsg diagnosis)
Etiology (R/T factor)
Signs & symptoms AEB
Who will assist the client? What equipment is required? How long of time is required?
Questions to ask when planning interventions.
Factual, complete, systematic.
Characteristics of nsg assessment.
Client, family, client's state of health or wellness.
Multiple sources of data.
P
Planning. Prioritize problems according to client needs. Develop goals & interventions.
Think, gather, analyze, evaluate, determination.
Using critical thinking & clinical reasoning.
Biophysical, psychological, sociocultural, spiritual, environmental.
Necessary client information.
Medical records, diagnostic tests, health history.
Sources of client information.
Organized frameworkv for nursing practice.
Nsg process.
I
Implementation. Initiate care plan & document to report information.
Undesirable response to a health condition.
Problem-focused nsg diagnosis.
Ideally a nurse can treat independently.
Etiology (R/T factor).
Performed within 24-hours of admittance.
Client initial comprehensive assessment. (Baseline data for patient care.)
Subjective & objective.
Data used to diagnose client problems.
E
Evaluation. Revisit goals, assess client, & use critical thinking to formulate a judgement.
Cluster to find common pattern.
Make a nursing diagnosis.
Defining characteristics.
S/S identified during assessment that is connected with AEB.
Sharp & unrelenting pain, VS deviated from normal, change in LOC.
Assessment information that requires immediate reporting.