CH 15-19 The Nursing Process

Nursing Process

systematic method nurses use to collect information, identify patient problems, decide what needs to be done, do it, and determine whether it worked

• assessment

• diagnosis

• planning

• implementation

• evaluation

Primary Data

obtained directly from the patient

Secondary Data

obtained from family, chart, prior documentation, or other clinicians

Cue

a piece of information that may tell you something important about your patient

Medical Diagnosis

identifies the disease/ pathology

Nursing Diagnosis

identifies the patient’s response to a health problem the nurse can address

Assessment

What am I seeing/ hearing?

Nursing Diagnosis

What does this tell me?

Planning/ Priority

What matters most right now?

Implementation

What should I do?

Evaluation

Did the patient improve?

3 Categories of Nursing Interventions

• independent

• dependent

• collaborative

Examples of independent factors

• repositioning

• patient education

• fall precautions

• therapeutic communications

• monitoring

Examples of dependent factors

• administering prescribed medications

• initiating ordered oxygen therapy

• implementing prescribed treatments

Examples of collaborative factors

• physical therapy

• respiratory therapy

• dietitian

• social work