Overview Of Nursing Process

• Phases of the Nursing Process:

  • Assessment/Assessing: to establish a data base through systematic and continuous collection, organization, validation, and documentation of data
  • Diagnosis: to identify the client's healthcare needs and prepare diagnostic statements
  • Planning: to identify the client's goal and appropriate nursing interventions
  • Implementation/Interventions: to give appropriate, holistic, and prompt quality healthcare service to the client
  • Evaluation: to determine the client's response to the interventions rendered
• Types of Assessment:

  • Initial Comprehensive Assessment: performed within a specified time after admission to a healthcare agency to establish a complete database for problem identification
  • Ongoing or Partial Assessment: data collection that occurs after the comprehensive database is established
  • Focused or Problem-Oriented Assessment: a thorough assessment of a particular client problem
  • Emergency Assessment: done during any physiological or psychological crisis of the client
• Components of Nursing Diagnosis:

  • Problem: statement of the client's response
  • Etiology: factors contributing to or probable causes of the response
  • Signs and Symptoms: defining characteristics manifested by the patient
• Factors when Assigning Priorities:

  • Clients' health values and beliefs
  • Clients' priorities
  • Resources available to the nurse and client
  • Urgency of the health problem
  • Medical treatment plan
• Formulate Nursing Goals/Client-Outcome Criteria:

  • Specific
  • Measurable
  • Attainable
  • Realistic
  • Time-bound
• Types of Nursing Goals:

  • Short-term Goal: outcome that can be attained in an hour to days
  • Long-term Goal: outcome that can be met in weeks to months
• Types of Nursing Interventions:

  • Independent
  • Dependent
  • Collaborative
• Types of Evaluation:

  • Ongoing Evaluation
  • Intermittent Evaluation
  • Terminal Evaluation
• Possible Judgments/Evaluation of the Outcome:

  • Completely Met/Goal Met
  • Partially Met
  • Completely Unmet/Goal Not Met
  • New problems or nursing diagnoses have emerged or developed