PNUR124 WEEK 1 STUDY GUIDE
1. What is the Nursing Process and 11-Needs Assessment Guide?
The Nursing Process is a 5 step clinical
decision-making approach
Nurses apply the nursing process as a
critical thinking competency when
delivering patient care.
The purpose of the nursing process is to
assist nurses in identifying and treating
patients' health-related concerns and
help patients attain agreed-upon health
outcomes
When you use the nursing process, you
identify a patient's health-related
concerns, clearly define a nursing diagnosis or collaborative problem, determine
priorities of care, and set goals and expected outcomes of care.
Then you develop and communicate a plan of care, perform nursing interventions,
and evaluate the effects of your care. Involving your patient in each step of the
nursing process helps ensure that care is patient centered.
As you become more competent in using the nursing process, you will be able to
focus on multiple problems or diagnoses and move back and forth between steps
when considering all the information available to you about a patient's concerns.
1. Assessment
a. Data collection
b. Data validation
c. Data analysis
2. Diagnosis – analyze the assessment data to determine issues and make a
clinical judgement
a. NANDA format
b. Establishin priorities
3. Planning – create a plan to attain an expected outcome
a. SMART patient goals
b. Nursing interventions/orders (what, when, how)
4. Implementation – carry out the plan
a. Carry out the intervention
5. Evaluation – response to the interventions/determine if it was effective
a. Seeing if patient goal is met or not
The Needs Assessment Guides are used to assist in collecting data according to
“Needs Assessment Guides.”
o Each guide will outline the usual data for the need, under subjective,
objective, and diagnostic tests
2. Define Clinical Reasoning
Clinical reasoning is the process used to examine and analyze patient care issues
at the point of care
1. What is the Nursing Process and 11-Needs Assessment Guide?
The Nursing Process is a 5 step clinical
decision-making approach
Nurses apply the nursing process as a
critical thinking competency when
delivering patient care.
The purpose of the nursing process is to
assist nurses in identifying and treating
patients' health-related concerns and
help patients attain agreed-upon health
outcomes
When you use the nursing process, you
identify a patient's health-related
concerns, clearly define a nursing diagnosis or collaborative problem, determine
priorities of care, and set goals and expected outcomes of care.
Then you develop and communicate a plan of care, perform nursing interventions,
and evaluate the effects of your care. Involving your patient in each step of the
nursing process helps ensure that care is patient centered.
As you become more competent in using the nursing process, you will be able to
focus on multiple problems or diagnoses and move back and forth between steps
when considering all the information available to you about a patient's concerns.
1. Assessment
a. Data collection
b. Data validation
c. Data analysis
2. Diagnosis – analyze the assessment data to determine issues and make a
clinical judgement
a. NANDA format
b. Establishin priorities
3. Planning – create a plan to attain an expected outcome
a. SMART patient goals
b. Nursing interventions/orders (what, when, how)
4. Implementation – carry out the plan
a. Carry out the intervention
5. Evaluation – response to the interventions/determine if it was effective
a. Seeing if patient goal is met or not
The Needs Assessment Guides are used to assist in collecting data according to
“Needs Assessment Guides.”
o Each guide will outline the usual data for the need, under subjective,
objective, and diagnostic tests
2. Define Clinical Reasoning
Clinical reasoning is the process used to examine and analyze patient care issues
at the point of care
