Nursing Process

• Assessment involves gathering data about the client's health status through observation, interview, examination, and testing.
• Nursing process includes assessment, diagnosis, planning, implementation, and evaluation.
• Assessment in nursing process is the process of gathering, sorting, and analyzing a patient's health information using evidenced foods.
• Purposes of assessment in nursing process are to establish a data base, determine resources, and determine patient's response to health concerns or illness.
• Data collected in nursing process includes subjective data (symptoms or sensations reported by the patient) and objective data (signs, which are detectable by an observer mainly using inspection, percussion, palpation, and auscultation).
• Methods of data collection in nursing process include interview, physical assessment, patient history, and sources of data can be primary (patient), secondary (significant others, healthcare team, medical records), or tertiary (books).
• Nursing process includes assessment, diagnosis, planning, implementation, and evaluation.
• Validating data in nursing process involves checking, verifying, and completing the data, distinguishing between cues and inferences, and acquiring additional details that may have been overlooked.
• Assessment in nursing process involves gathering, sorting, and analyzing a patient's health information using evidenced foods.
• Diagnosis in nursing process is the process of interpreting assessment data, identifying client strengths and health problems, and formulating diagnostic statements.
• Purposes of assessment in nursing process are to establish a data base, determine resources, and determine patient's response to health concerns or illness.
• Types of diagnosis in nursing process include problem-forsed diagnosis, risk diagnosis, wellness for health promotion diagnosis, and syndrome.
• Data collected in nursing process includes subjective data (symptoms or sensations reported by the patient) and objective data (signs, which are detectable by an observer mainly using inspection, percussion, palpation, and auscultation).
• Planning in nursing process involves how to manage the problem, with the nurse and client developing client goals/ desired outcomes and nursing strategies to prevent, reduce, or alleviate the client's health problems.
• Data collection in nursing process can be done through interview, physical assessment, patient history, and other sources such as significant others, healthcare team, and medical records.
• Types of planning in nursing process include initial planning (upon admission or in the ER), ongoing planning (during every shift), and discharge planning (upon discharge).
• Validating data in nursing process involves checking, verifying, and completing the data, distinguishing between cues and inferences, and acquiring additional details that may have been overlooked.
• Implementation in nursing process involves reassessing the client, determining the nurse's needs for assistance, and implementing the nursing interventions.
• Diagnosis in nursing process involves interpreting assessment data, identifying client strengths and health problems, and formulating diagnostic statements.
• Delegation in nursing process is the process for a nurse to direct another person to perform nursing tasks and activities.
• Types of diagnosis in nursing process include problem-forsed diagnosis, risk diagnosis, wellness for health promotion diagnosis, and syndrome.
• Evaluation in nursing process involves client and health care professionals determining the client's progress toward goal achievement and the effectiveness of the nursing care plan.
• Planning in nursing process involves managing the problem, developing client goals/ desired outcomes, and selecting nursing strategies.
• Types of planning in nursing process include initial planning, ongoing planning, and discharge planning.
• Desired outcomes in nursing process are used to evaluate the client's response to nursing care and serve two purposes: establish the kind of evaluation data that needs to be collected and provide a standard against which the data are judged.
• Implementation in nursing process involves reassessing the client, determining the nurse's needs for assistance, and implementing the nursing interventions.
• Delegation in nursing process is the process for a nurse to direct another person to perform nursing tasks and activities.
• Evaluation in nursing process involves determining the client's progress toward goal achievement and the effectiveness of the nursing care plan.
• Desired outcomes in nursing process are used to evaluate the client's response to nursing care and provide a standard against which the data are judged.