HA LEC EXAM

• Lydia Hall introduced the term nursing process


  1955
• Johnson, Orlando and Wiedenbach were among the first to use it to refer to a series of phases describing the practice of nursing


  1963
• Purpose of the Nursing Process

  • To identify a client's health status and actual and potential health care problems or needs
  • To establish plans to meet identified needs
  • To deliver specific nursing interventions to meet those needs
• Characteristics of the Nursing Process

  • Cyclic and dynamic
  • Client-centered
  • An adaptation of problem solving process
  • Decision-making is involved in every phase
  • Interpersonal and collaborative
  • Universal
  • Use of critical thinking
• Phases of Nursing Process

  1. Assessment

  2. Diagnosis

  3. Planning

  4. Implementation

  5. Evaluation
• Assessment


  1. Collecting Data

  2. Organizing Data

  3. Validating Data

  4. Documenting Data
• Nursing Diagnosis


  • A clinical judgment about individual, family, or community responses to actual and potential health problems/life processes
  • Provides basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable
• Steps in Diagnosis


  1. Analyzing data

  2. Identify health problems, risks and strengths

  3. Formulate diagnostic statements
• Steps in Planning


  1. Priority Setting

  2. Establishing client goals/desired outcomes

  3. Selecting nursing interventions

  4. Writing individualized interventions
• Implementing Skills


  1. Cognitive

  2. Interpersonal

  3. Technical
• Steps in Implementing


  1. Reassessing the client

  2. Determining the nurse's need for assistance

  3. Implementing the nursing interventions

  4. Supervising the delegated

  5. Documenting nursing activities
• Steps in Evaluating


  1. Collecting data related to desired outcomes

  2. Comparing data with outcomes

  3. Relating nursing activities to outcomes

  4. Drawing conclusions about problem status

  5. Continuing, modifying, or terminating the nursing care plan