Nursing Process

Study Notes

The nursing process is a systematic, problem-solving approach used to deliver individualized nursing care to patients.

Assessment: Collect and analyze data about the patient's health status, including physical, emotional, and psychological aspects.
- Types of assessment:
  - Initial assessment: First encounter with the patient
  - Ongoing assessment: Continuous monitoring of the patient's condition
  - Focused assessment: Targeted evaluation of a specific problem or issue
Diagnosis: Identify actual or potential health problems based on the assessment data.
- Nursing diagnosis: A statement that describes the patient's specific health problem or need.
Planning: Develop a plan of care to address the identified health problems.
- Goals: Specific, measurable, achievable, realistic, and time-bound (SMART) outcomes desired for the patient.
- Interventions: Actions taken to achieve the goals, including nursing actions, medications, and treatments.
Implementation: Carry out the planned interventions to achieve the desired outcomes.
- Nursing actions: Direct care provided to the patient, such as administering medications, performing procedures, and providing education.
Evaluation: Monitor and assess the patient's response to the interventions and adjust the plan of care as needed.
- Outcome evaluation: Determine whether the desired outcomes were achieved.
- Process evaluation: Assess the effectiveness of the nursing process itself.

Patient-centered care: Focus on the patient's unique needs, values, and preferences.
Individualized care: Tailor the plan of care to the patient's specific health needs and circumstances.
Collaboration: Work with other healthcare professionals to provide comprehensive care.
Evidence-based practice: Use current research and evidence to inform nursing decisions and actions.

A systematic, problem-solving approach used to deliver individualized nursing care to patients.

Assessment: Collect and analyze data about the patient's health status, including physical, emotional, and psychological aspects.
- Includes initial assessment, ongoing assessment, and focused assessment.
Diagnosis: Identify actual or potential health problems based on the assessment data.
- Includes nursing diagnosis, a statement that describes the patient's specific health problem or need.
Planning: Develop a plan of care to address the identified health problems.
- Includes setting SMART goals and identifying interventions, such as nursing actions, medications, and treatments.
Implementation: Carry out the planned interventions to achieve the desired outcomes.
- Includes direct care provided to the patient, such as administering medications, performing procedures, and providing education.
Evaluation: Monitor and assess the patient's response to the interventions and adjust the plan of care as needed.
- Includes outcome evaluation and process evaluation.

Patient-centered care: Focus on the patient's unique needs, values, and preferences.
Individualized care: Tailor the plan of care to the patient's specific health needs and circumstances.
Collaboration: Work with other healthcare professionals to provide comprehensive care.
Evidence-based practice: Use current research and evidence to inform nursing decisions and actions.