THE NURSING PROCESS A systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness. A systematic way to plan, implement and evaluate care for individuals, families, groups and communities.

Characteristics of the Nursing Process Dynamic Client-centered Planned Interpersonal and collaborative Universally applicable Can focus on problems or strengths

ASSESSMENT Collect, organize, validate data Obtain information from charts, client, family Data gathering (no conclusions) Establish information about person’s response to health concerns and ability to manage

DATA COLLECTION Observation Interview Types of questions Setting Rapport Examination

DIAGNOSIS Sort, cluster, analyze information Identify potential problems and strengths Write statement of problem or strength Risk of infection related to compromised nutrition Potential for effective breastfeeding related to knowledge level and support system Prioritize the problems Not a medical diagnosis

TYPES OF DIAGNOSIS Actual diagnosis – problem is present Risk nursing diagnosis Possible diagnosis Wellness diagnosis

PLANNING Establish the goals, interventions and outcomes

IMPLEMENTATION Carry out the plan Assist person to meet goals; facilitate coping Continue to collect data Document care

EVALUATION Determine if goals were met Should care continue Modify plan if necessary

Benefits of using the nursing process Continuity of care Prevention of duplication Individualized care Increased client participation Collaboration of care Standards of care

NANDA – North American Nursing Diagnosis Association Identifies nursing functions Creates classification system Establishes diagnostic labels Risk of infection related to compromised nutritional state Potential complication of seizure disorder related to medication compliance

Creating nursing diagnosis statements State the person’s response or diagnostic label Identify related factors contributing to or causing the problem Signs and symptoms

Qualities for application of the nursing process Intellectual skills Critical thinking Decision-making Interpersonal skills Technical skills Creativity Adaptability