NURSING PROCESS

NURSING PROCESS
Identify a clients health status and actual or potential health care problems or needs. Establish plans to meet identified needs. To deliver specific nursing interventions to meet identified needs.

CHARACTERISTICS OF THE NURSING PROCESS

Data from each phase provide input to the next phase. The nursing process is client centered. The nursing process is an adaptation of problem solving and systems theory.

CHARACTERISTICS OF THE NURSING PROCESS

Decision making is involved in every phase of the nursing process. The nursing process is interpersonal and collaborative. It is universal. Critical thinking is involved in every phase.

NURSING PROCESS
ASSESSMENT

EVALUATION
CRITICAL THINKING

DIAGNOSIS

IMPLEMEN TATION

PLANNING

PHASES OF NURSING PROCESS

Assessment Diagnosis Planning Implementation Evaluation

ASSESSMENT

Collecting, organizing, validating and documenting client data.

ACTIVITIES INVOLVED IN ASSESSMENT

Establish a data base: Obtain a nursing health history. Conduct a physical assessment. Review client records. Review nursing literature. Consult support persons. Consult health professional.

ACTIVITIES INVOLVED IN ASSESSMENT

Update data as needed. Organize data. Validate data. Communicate/ document data.

DIAGNOSIS
Analyzing and synthesizing data. To identify clients:

Strengths Health problems

To develop a list of nursing and collaborative problems.

ACTIVITIES INVOLVED IN DIAGNOSING

Interpret and analyze data. Determine clients strengths, risks, diagnoses and problems. Formulate nursing diagnosis. Document nursing diagnosis on the care plan.

PLANNING
Determining how to prevent, reduce or resolved the identified priority client problems. Determining how to support client strengths. Determining how to implement nursing interventions.

PLANNING

To develop an individualized care plan that specifies clients goals/ desired outcomes and related nursing intervention.

ACTIVITIES INVOLVED IN PLANNING

Set priorities and goals/ outcomes in collaboration with the client. Write goals and desired outcomes. Select nursing intervention and strategies.

ACTIVITIES INVOLVED IN PLANNING

Consult other health care professionals. Communicate care plan to relevant health care providers.

IMPLEMENTATION
Carrying out (or delegating) and documenting the planned nursing intervention. To assist client to meet desired outcomes/goals, promote wellness; prevent illness and disease; restore health and facilitate coping.

ACTIVITIES INVOLVED IN IMPLEMENTATION

Reassess the client to update the database. Determine the nurses need for assistance. Perform planned nursing interventions.

EVALUATION
Measuring the degree to which goals/outcomes have been achieved. Identifying factors that have positively or negatively influenced goal achievement.

ACTIVITIES INVOLVED IN EVALUATION

Collaborate with client and collect data related to desired outcomes. Judge whether goals/ outcomes have been achieved. Review and modify the care plan as indicated.