Nursing Process

• nursing is the diagnosis and treatment of human responses and to health and illness
• nursing process is a systematic organized method of planning and providing quality and individualized nursing care
• assessment is the first step of nursing process which involves the systematic collection of data and also the most important step. It sets the tone for the rest of the process and the rest of the process flows from it
• diagnosis is the 2nd step of the nursing process where analysis of data is done to identify the problem, it involves identifying and prioritizing actual or potential health problems or responses
• actual nursing diagnosis identifes an occurring health problem for your patient
• potential nursing diagnosis identifies a high-risk health problem that most likely will occur unless preventive measures are taken
• possible nursing diagnosis is one that needs further data to support it
• signs and symptoms are the observable assessment cues such as patient behavior, physical signs
• etiology is the cuase or causative factor for diagnosis
• planning is the 3rd step of the nursing process and involves setting goals and outcomes and it is an individualized plan of care for your patient is ready once diagnosis have been prioritized
• priority setting is the ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions
• goals is a broad statement that describes a desired change in a patient’s condition, perceptions or behavior
• long term goals is an objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks or months 
• short term goals is an objective behavior or response that you expect the patient to achieve in short time usually few hours or less than a week
• intervention is the 4th step of nursing process and is also called implementation and known as the doing phase. This is where the plan is put into action and involves carrying out your plan to achieve goals and outcomes
• direct care are the treatment performed through interaction with patient
• indirect care are the treatments performed away form a patient but on behalf of the patient or group of patient
• independent is an action that the nurse initiates without supervision or direction from others
• dependent is the actions that require an order from a health care provider
• collaborative is known as the interdependent interventions that require the combined knowledge, skills, and expertise of multiple health care providers
• evaluation is the 5th/final step of the nursing process and it is crucial to determine if the patient’s condition improved or worsen after application of the first four steps of nursing process it also involves determining the effectiveness of your plan
• assessment is the deliberate and systematic collection of data to determine a client’s current and past health status and functional status and to determine the client’s present and coping patterns
• initial comprehensive assessment involves collection of subjective data about the client’s perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices as well as objective data gathered during a step-by-step physical examination
• focused or problem oriented assessment is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern, it consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem
• emergency assessment is a very rapid assessment performed in life-threatening situations that needs an immediate asssessment to provide prompt treatment
• acute care nurse performs a focused assessment, and then incorporates assessment findings with a multidisciplinary team to develop a comprehensive plan of care.
• critical care outreach nurses need enhanced assessment skills to safely assess critically ill clients who are outside the structured intensive care environment
• ambulatory care nurses assess and screen clients to determine the need for physician referrals.
• home health nurses make independent nursing diagnoses and referrals for collaborative problems as needed
• public health nurses assess the needs of communities, school nurses monitor the growth and health of children, and hospice nurses assess the needs of the terminally ill clients and their families.
• late 1800s-early 1900s where nurses relied on their natural senses; the client’s face and body would be observed for “changes in color, temperature, muscle strength, use of limbs, body output, and degrees of nutrition, and hydration”
• palpation was used to measure pulse rate and quality and to locate the fundus of the puerperal woman
• 1930-1949 where the American Journal of Public Health documents routine client and home inspection by public health nurses in the 1930s
• 1950-1969 this is where the nurses were hired to conduct pre-employment health stories and physical examinations for major companies, such as New York Telephone, from 1953 through 1960
• 1970-1989 the nurses develop an active role in the provision of primary health services and expanded the professional nurse role in conducting health histories and physical and psychological assessments
• 1990-present where the advanced practice nurses have been increasingly used in the hospital as clinical nurse specialists and in the community as nurse practitioners
• physical refers to the body, this marvelous container and complex, finely tuned, machine with which we interface with our environment and fellow beings. The physical self is the concrete dimension, the tangible aspect of the person that can be directly observed and examined.
• psychological pertaining to the mind or to mental phenomena as the subject matter of psychology. of, pertaining to, dealing with, or affecting the mind, especially as a function of awareness, feeling, or motivation: psychological play; psychological effect
• sociological relating to sociology or to the methodological approach of sociology. Oriented or directed toward social needs and problems.
• cultural is the characteristics and knowledge of a particular group of people, encompassing language, religion, cuisine, social habits, music and arts