The Nursing Process
The common thread uniting different types of nurses who work in varied areas is the
nursing process-the essential core of practice for the registered nurse to deliver
holistic, patient-focused care. One definition of the nursing process..."an
assertive, problem solving approach to the identification and treatment of patient
problems. It provides an organizing framework for the practice of nursing and the
knowledge, judgments, and actions that nurses bring to patient care."
Assessment
An RN uses a systematic, dynamic, rather than static way to collect and analyze
data about a client, the first step in delivering nursing care. Assessment includes
not only physiological data, but also psychological, sociocultural, spiritual,
economic, and life-style factors as well. For example, a nurse's assessment of a
hospitalized patient in pain includes not only the physical causes and
manifestations of pain, but the patient's response-an inability to get out of bed,
refusal to eat, withdrawal from family members, anger directed at hospital staff,
fear, or request for more pain medication.
Diagnosis
The nursing diagnosis is the nurse's clinical judgment about the client's response
to actual or potential health conditions or needs. The diagnosis reflects not only
that the patient is in pain, but that the pain has caused other problems such as
anxiety, poor nutrition, and conflict within the family, or has the potential to
cause complications-for example; respiratory infection is a potential hazard to an
immobilized patient. The diagnosis is the basis for the nurse's care plan.
Planning / Goal / Outcome
Based on the assessment and diagnosis, the nurse sets measurable and achievable
short- and long-range goals for this patient that might include moving from bed to
chair at least three times per day; maintaining adequate nutrition by eating
smaller, more frequent meals; resolving conflict through counseling, or managing
pain through adequate medication. Assessment data, diagnosis, and goals are written
in the patient's care plan so that nurses as well as other health professionals
caring for the patient have access to it.
Implementation
Nursing care is implemented according to the care plan, so continuity of care for
the patient during hospitalization and in preparation for discharge needs to be
assured. Care is documented in the patient's record.
Evaluation
Both the patient's status and the effectiveness of the nursing care must be
continuously evaluated, and the care plan modified as needed.
11/26/12 kwb: NP overview - Transfer students
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