Nursing Review: Nursing Process

ASSESSMENT PHASE Data Collection Organize Data Validate Data Document Data	Subjective Data  also referred to as symptoms or covert data Objective Data also referred to as signs or overt data, are detectable by an observer Primary source is the client Secondary source is family or anyone else that is not the client Methods of Data Collection Observing To observe is to gather data by using the sense. Interviewing Is a planned communication or a conversation with purpose Examining Is a systematic data-collection method that uses observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems.
DIAGNOSIS PHASE Analyze Data Identify Health Problem Formulate Diagnostic Statements Diagnostic Statements Problem (P): statement of the client’s response. Etiology (E): factors contributing Signs and Symptoms (S): defining characteristics manifested by the client	Types of Nursing Diagnosis Actual diagnosis is a client problem that is present at the time of the nursing assessment. Risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors Wellness diagnosis Possible nursing diagnosis is one in which evidence about a health problem is incomplete or unclear. Syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses .
PLANNING PHASE Prioritize problems Formulate goals Select actions Write nursing orders	Types of Planning Initial planning, admission assessment. Ongoing planning Discharge planning: M edications E xercise T reatment/therapy H ygiene O ut-patient follow up D iet/nutrition S exual activity/spirituality
INTERVENTION / IMPLEMENTATION Determining needs for assistance Putting into action the plan Supervising delegated care Documenting nursing activities	Types of Intervention   Independent   Dependent   Collaborative Cognitive or Intellectual Skills Such as analyzing the problem, problem solving, critical thinking and making judgments regarding the patient's needs. Interpersonal Skills Which includes therapeutic communication, active listening, conveying knowledge and information, developing trust or rapport-building with the patient Technical Skills Which includes knowledge and skills needed to properly and safely done the procedure
EVALUATION PHASE	Collecting data related to outcome Comparing data Drawing conclusion Continuing, modifying or  terminating the nursing care plan