Professional Documents
Culture Documents
NURSING PROCESS
1. Assessment
2. Nursing Diagnosis (What’s the problem? What are the patient’s needs?)
3. Planning (What needs to be done?)
4. Implementation (Do what needs to be done to meet the patient’s needs.)
5. Evaluate / Reassess (Have the patient’s needs been met?)
6. Documentation (If you don’t write it, you didn’t do it!!)
- documentation allows for thorough assessments to be passed to
others and followed up
STEP I ASSESSMENT
subjective data (covert) – information that the patient gives to the care
provider
objective data (overt) – information that you gather from assessing (looking,
touching, hearing) the patient
- may better define patient’s condition and help in planning care
STEP 3 DIAGNOSIS
- classifying
- purpose is to identify how an individual responds to actual or potential health
and life processes, identify
factors that contribute to or cause health problems (etiologies), and
identify resources or strengths that
can be drawn on to prevent of resolve problems
plan of nursing care (patient care plan) – written guide that directs the
efforts of the nursing team as nurses
work with patients to meet their health goals
- specifies nursing diagnoses, outcomes, and associated nursing
interventions
STEP 6 INTERVENTIONS
- nursing actions planned in previous step are carried out
- patient is primary in determining how nursing interventions are implemented
- successful nurses modify actions according to patient’s changing ability
and willingness to participate
in the plan of care and previous responses to nursing interventions
and progress toward
goal/outcome achievement
STEP 7 EVALUATION
- nurse and patient together measure how well the patient has achieved the
outcomes specified in the plan of
care; however, the patient is always the nurse’s primary concern
- functions to determine whether the outcomes have been or are being met and
then identifying the
appropriate nursing response
* Goal Met
* Goal Partially Met
* Goal Not Met
- based on the patient’s responses to the plan of care (feedback), the nurse
decides to
• terminate plan when each expected outcome is achieved
• modify the plan if there are difficulties achieving the outcomes
• continue the plan if more time is needed to achieve the outcomes