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Nursing Process
Nursing Process
Nursing Process
NUR PROCESS
SING
nursing process – a systematic problem solving approach toward providing individualized nursing
care.
NANDA-I – North American Nursing Diagnosis Association International
CHARACTERISTICS OF THE NURSING PROCESS
1. Framework for care to individuals, families, & communities
2. Orderly & systematic
3. Interdependent
4. Provides specific care for the individuals, family, & community
5. Client centered
6. Appropriate for use throughout lifespan
7. Used in ALL settings
steps of the nursing process?
ADPIE
Assessment – Collect data; Organize data; Validate data; Document data
Diagnosis – Analyze data; Identify health problems, risks, and strengths; Formulate
diagnostic statements
Planning – Prioritize problems/diagnoses; Formulate goals/desired outcomes; Select
Nursing Interventions; Write nursing interventions
Implementation – Reassess the client; Determine the nurse's need for assistance;
Implement the nursing interventions; Supervise delegated care; Document nursing
activities
Evaluation – Collect data related to outcomes; Compare data with outcomes; Relate
nursing actions to client goals/outcomes; Draw conclusions about problem status;
Continue, modify, or terminate the client's care plan
How does the nurse obtain assessment info?
Initial (or admission assessment)
Focused assessment – Collects data about a problem that has already been identified. This type of
assessment determines whether the problem still exists, or any changes.
Emergency assessment – Performed to identify a life‐threatening problem (choking, stab wound,
heart attack).
How does the nurse obtain assessment info?
past medical hx
family hx
reason for admission
current meds
previous hospitalizations & surgeries
psychosocial assessment
nutrition - complete physical assessment
DATA COLLECTION
subjective data – Information verbalized or stated by the client. (symptoms)
objective data – Observable and measurable information. Remember to include your senses: smell,
hearing, touch and sight. (signs)
sign – An objective finding perceived by the examiner ex. (fever, rash, etc.)
symptom – Subjective findings verbalized or stated by the client ex. ("I have a headache" " I feel
sick in my stomach.")
2 SOURCES OF DATA
o PRIMARY – Information obtained from the patient (only)
o SECONDARY – Family members; Significant others; Past & current health records,
laboratory tests, diagnostic procedures, consultations from other healthcare professionals.
COLLECT THE DATA THEN BLANK THE DATA
VALIDATE – Confirm and verify the information. Keep it free from errors, bias, or misinterpretation.
CLUSTERING – clustering of data often contains defining characteristics which are specific
assessment findings that support nursing diagnosis.
During the clustering of data what is used critical thinking is used to analyze and synthesize the
information that is collected. The data is then put into specific clusters that describe a specific
client problem.
IDENTIFY HOW YOU DEVELOP A NURSING DIAGNOSIS (WHAT IS FIRST / NEXT ETC)
1. Complete thorough assessment of the patient.
2. Highlight or underline relevant symptoms (defining characteristics).
3. Make a list of symptoms.
4. Cluster and interpret the symptoms.
5. Analyze and interpret the symptoms.
6. Select a nursing diagnosis based on the definition found in the nursing diagnosis manual by Doenges,
Moorhouse and Murr.
7. Remember to prioritize the identified problems.
A medical diagnosis describes a disease process. A nursing diagnosis describes an individual, family or