The nursing process
decision making framework used by all nurses to determine the needs of their patients and to decide how to care for them
Steps of the nursing process
Assessment
gathering of information through signs and symptoms, patient history, and both subjective and objective findings
Steps of the nursing process
Diagnosis
formulation of nursing diagnosis through an analysis of the assessment information that you have gathered
Steps of the nursing process
Planning
the process of determining priorities and what nursing actions should be performed to help resolve or manage each patient problem
Steps of the nursing process
Implementation
the process of taking actions to resolve the patients problem, also known as intervention
Steps of the nursing process
Evaluation
performed when the nurse reflects on the interventions performed and decides wether the patient is now closer to achieving the goals and outcomes set in the planning step, if not the nurse revises and changes the intervention
Objective date
things you can actually see
subjective data
information that is known only to the patient and family members
Nursing goal
the overall direction in which one must progress to improve a problem
expected outcomes
statements of measurable action for the patient within a specific time frame and in response to nursing interventions
direct patient care
when the nurse interacts directly with the patient
indirect patient care
performed when the nurse provides assistance in setting other than with the patient
independent interventions
providing intervention without consulting anyone
Dependent interventions
some nursing interventions do require a health care providers order before they can be preformed
Collaborative interventions
those that involve working with other health care professionals in the hospital setting
Clinical judement
when nurses take their critical thinking and turn it into nursing actions
Clinical Judgment steps
- recognize cue
- analyze cue
- prioritize
- take action
- evaluate outcome
Smart goals
- Specific
- Measurable
- Attainable
- Realistic
- Time limited