Nursing process

• <S: >The nursing process consists of five steps: assessment, nursing diagnosis, planning, implementation, and evaluation.
• <I: >Planning involves developing goals and objectives based on the patient's needs and desired outcomes.
• <R: >Nurses use this data to identify problems or concerns that require intervention.
• <A: >Assessment is the first step in the nursing process where nurses gather information about their patients' health status through observation, interview, examination, and review of medical records.
• During the assessment phase of the nursing process, the nurse collects data about the patient's health status, including physical, psychological, social, and cultural factors.
• The nursing diagnosis is the problem or concern that needs to be addressed.
• The nurse may use auscultation to listen to the patient's heart and lung sounds.
• They assist the nurse in focusing assessment, identifying outcomes, and facilitating evaluation of care.
• Nursing diagnoses are clinical judgments about the nature and severity of healthcare issues encountered when providing care to individuals, families, groups, or communities.
• Nursing diagnoses provide the basis for the selection of nursing interventions to achieve outcomes for which the nurse has accountability.
• Pre-introductory Phase:

  • Nurse reviews the medical record before meeting the client
  • Provides insights into biographical information and potential communication considerations
  • Reveals past health history and reasons for seeking healthcare
  • In cases without a medical record, relies on interviewing skills to gather valid data
• Introductory Phase:

  • Nurse introduces herself to the client
  • Explains the purpose of the interview and the types of questions to be asked
  • Discusses the reason for taking notes
  • Assures the client of the confidentiality of information, adhering to Health Insurance Portability and Accountability Act (HIPAA) guidelines
• Working Phase:

  • Elicits client's comments on major biographical data
  • Explores reasons for seeking care
  • Gathers information on the history of present health concern
  • Discusses past health history and family history
  • Reviews body systems (ROS) for current health problems
  • Explores lifestyle and health practices
  • Assesses developmental level
• Summary and Closing Phase:

  • Nurse summarizes information obtained during the working phase
  • Validates problems and goals with the client
  • Identifies and discusses possible plans to resolve problems (client concerns and collaborative problems)