Nursing Process

• Nursing Process - organized sequence of problem-solving steps used to identify and to manage the health problems of clients.
• Nursing Process - systemic, rational method of providing individualized nursing care.
• Medical assessments - Focus on the client’s

  disease.
• Nursing assessments - Focus on the client’s response to disease.
• Critical thinking - includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”
• Critical thinking - accuracy of patient information is validated
• Critical Reasoning - uses formal and informal thinking strategies to gather and analyze patient information
• Inductive Reasoning - involves noticing cues, making generalizations, and creating hypotheses.
• Cues - are data that fall outside of expected findings that give the nurse a hint or indication of a patient’s potential problem or condition.
• Generalization - is a judgment formed from a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes more clear.
• hypothesis - is a proposed explanation for a situation.
• Assessment - process of gathering, verifying and communicating data about a client
• Assessment - describes client’s health problems or response for nursing therapy given.
• Comprehensive initial - provide baseline client data shortly after admission
• Focused - limited in the scope targets a particular need or health care concern.
• Ongoing – systematic monitoring & observation related to specific problem.
• Data collection - it is the process of gathering information about a client’s health status.
• Objective data - (signs) Observable and measurable data
• Subjective data - (symptoms) Information perceived only by the affected person
• Validating Data - act of “double-checking” or verifying data to confirm that they are accurate.
• Inference - what you think, a judgment about the cues
• Nursing Diagnosis - clinical judgment about individual, family, or community responses to actual or potential health problems/ life processes.
• nursing diagnosis - provides the basis for selection of nursing interventions
• Medical Diagnosis - Focuses on the illness, injury, or disease process
• Nursing diagnosis - Focuses on the client’s responses to actual or potential health problems
• Actual nursing diagnosis – a problem exists.
• Risk nursing diagnosis – indicates the problem doesn’t exist but has special risk factors
• Wellness nursing diagnosis – indicates the client’s desire to attain a higher level of wellness in some area of function.
• Problem statement – describes the client’s response to an actual or potential health problem (diagnostic label)
• Etiology – it cause of the problem
• The diagnostic label & etiology are linked by the terminology Related to (R/T)
• Qualifiers - (also called modifiers) are words that have been added to some diagnostic labels to give additional meaning. Exempted in this rule are one-word nursing diagnoses
• Defining characteristics - are the clusters of signs and symptoms that indicate the presence of a particular diagnostic label.
• Related factors - are etiological or other contributing factors that have influenced the health status change.
• Clinical cues - subjective and objective signs or symptoms that point to the nursing diagnosis
• Major defining characteristics must be present for

  diagnosis to be valid
• RISK DIAGNOSIS - Is a clinical judgment that an individual, family or community is more vulnerable to develop the problem than others
• P - Diagnostic Label
• E - Related factor
• S - Defining characteristics