Ch.4 The Nursing Process Flashcards
Assessment
Gathering patient information through, signs and symptoms, patient history, subjective and objective findings.
ie. Interview, head to toe assessment and reviewing laboratory and diagnostic test.
Diagnosis
The analysis of the assessment information that you have gathered, formulating a nurse diagnoses
Nursing Diagnosis
Related to the needs or problem a patient is experiencing. (Not a medical diagnoses) selected based on definitions and characteristics
Planning
The process of determining priorities and what nursing actions should be performed to help resolve or manage each patient problem…
Implementation
When the nurse performs the process of “taking action” to resolve the patient’s problems (interventions).
Evaluation
The nurse then reflects on the interventions performed and decides whether the patient is now closer in achieving the goals and outcomes that were set in the planning step
The Nursing Process
Five-step framework for decision making. Assessment, Diagnosis, planning, implementation, Evaluation (A.D.P.I.E).