ch 5

Explanations of Nursing Process Phases
- Explain the use of each of the six phases of the nursing process.
Elements of Nursing Process
- List the elements of each of the six phases of the nursing process.
Database Establishment
- Describe the establishment of the database.
Patient Problem Statement
- Discuss the components of a patient problem statement.
Types of Health Problems
- Differentiate between types of health problems.
Patient-Centered Goals
- Describe the development of patient-centered goals.
Nursing Orders Creation
- Discuss the creation of nursing orders.
Evaluation of Nursing Care
- Explain the evaluation of a nursing care plan.
Demonstration of the Nursing Process
- Demonstrate the nursing process by preparing a nursing care plan.
NANDA-I, NIC, NOC
- Explain North American Nursing Diagnosis Association International (NANDA-I), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC).
Clinical Pathways and Managed Care
- Describe the use of clinical pathways in managed care.
Critical Thinking
- Discuss critical thinking in nursing.
Evidence-Based Practice
- Define evidence-based practice.

According to the American Nurses Association (ANA), nursing is defined as:
- "Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations" (ANA, n.d.a).
This definition underscores the growth and dynamism of nursing as a profession.

Definition
- The nursing process is a systematic method by which nurses plan and deliver care.
- It utilizes a problem-solving approach that helps identify patient problems and potential problems.
- The phases of the nursing process are:
1. Assessment
2. Diagnosis
3. Outcomes Identification
4. Planning
5. Implementation
6. Evaluation

Definition: Assessment is defined by the ANA as:
- "A systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care." (ANA, n.d.b).
Types of Data Collected:
- Objective Data: Observable and measurable signs.
- Example: Blood pressure of 100/60 mm Hg.
- Subjective Data: Information provided by the patient, which includes symptoms.
- Example: "I feel nauseated" or "My chest hurts".
Methods of Data Collection
- Conduct an interview (nursing health history) to gather information about:
- Biographic data
- Reason for seeking healthcare
- Present and past health history
- Environmental factors
- Psychosocial history
- Conduct a physical examination:
- Guided by the symptoms reported from the patient.

Definition: To diagnose is to identify the type and cause of a health condition.
- Medical diagnoses are established by physicians or qualified healthcare providers.
- Nursing diagnoses (or patient problem statements) identify health problems that can be addressed by nursing.
Components of Patient Problem Statement:
- Identifying actual or potential patient problems based on assessment data.
- Example: A patient preparing for surgery may have a nursing diagnosis of "Potential for Discomfort".

Goal Setting:
- Develop patient-centered goals or expected outcomes directly related to nursing diagnoses.
Characteristics of Effective Goals:
- Should be measurable and specific to the patient's problem.
- Include realistic expectations based on the patient's situation.
- Have an explicit time frame for reevaluation.

Overview: Establish care priorities and select nursing interventions that address patient problems.
Frameworks for Planning: Often guided by Maslow’s Hierarchy of Needs, prioritizing health concerns based on their severity.
- Life-threatening issues take precedence over other concerns.
Documentation: Includes recording the planned goals and interventions.

Essential Actions:
- Execute the established care plan involving nursing actions, patient education, and collaboration with other healthcare team members.
- In emergency situations, the nursing process accelerates with immediate response actions taken directly following assessment.

Purpose: Evaluate the extent to which patient goals have been achieved.
- Steps include:
1. Reviewing established patient goals.
2. Reassessing the patient for data on their response to interventions.
3. Comparing actual outcomes versus desired outcomes.
4. Making judgments on whether the goals were met.
Documentation of Findings: All evaluations must be clearly documented for continuity of care.

NANDA-I (North American Nursing Diagnosis Association International): Set standards for nursing diagnoses.
NIC (Nursing Interventions Classification): Provides a framework for nursing interventions.
NOC (Nursing Outcomes Classification): Measures outcomes related to nursing care.

Definition: Critical thinking is the mental process of actively and skillfully analyzing, synthesizing, and evaluating information collected through observation and experience, leading to appropriate decisions about patient care.
Application and Importance:
- Essential in all nursing actions from patient assessment to the implementation of care plans.

Definition: EBP is a problem-solving approach that integrates the best available research with clinical expertise and patient values to facilitate high-quality healthcare delivery.
- EBP ensures accountability in nursing interventions.