Nursing Process
Define the nursing process✔✔ a systematic problem solving approach toward providing
individualized nursing care.
What is NANDA-I✔✔ North American Nursing
Diagnosis Association International
What are the characteristics of the nursing process?✔✔ 1-framework for care to indiv,
families, & communities 2-orderly & systematic 3-interdependent 4-provides specific care
for the indiv, fam, & comm 5- client centered 6-appropriate for use throughout lifespan 7-
used in ALL settings
What are the steps of the nursing process?✔✔ ADPIE A=assessment D=diagnosis
P=planning I=implementation E=evaluation
How does the nurse obtain assessment info?✔✔ 1- initial (or admission assessment) 2-
focused assessment 3- emergency assesment
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
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.
focused assessment questions✔✔ - What are your symptoms?
- When did they start?
- What activity were you doing ?
- What makes it better or worse?
- What are you doing to relieve the symptom?
Emergency assessment✔✔ Performed to identify a life-threatening problem (choking, stab
wound, heart attack).
subjective data✔✔ Information verbalized or stated by the client.
objective data✔✔ - Observable and measurable information.
- Remember to include your senses: smell, hearing, touch and sight.
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.")
signs are✔✔ objective
symptoms are✔✔ subjective
2 sources of data✔✔ primary & 2ndary
, primary source of data✔✔ -Information obtained from the patient (only)
secondary sources of data✔✔ - 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.
Data is 1,2,3✔✔ collected, validated, then clustered
clustering of data often contains✔✔ defining characteristics which are specific assessment
findings that support a
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 sources of data for obtaining information from the client✔✔ subjective & objective,
primary & secondary, people, healthcare professionals, medical chart, test & lab results etc
identify how you develop a nursing diagnosis✔✔ As you cluster data, you begin to consider
various diagnoses that may relate to the client. You must remember that if certain defining
characteristics do not exist for a specific diagnosis, then you must not use the diagnosis.
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.
what is the difference between a medical and nursing dx✔✔ A medical diagnosis describes
a disease process. A nursing diagnosis describes an individual, family or
group response to an actual or potential problem.
medical dx✔✔ -Identification of a disease condition based on specific
findings such as diagnostic tests and procedures.
- Remains the same as long as the disease is present.
nursing dx✔✔ - Clinical judgment in response to actual or potential
health problems.
Define the nursing process✔✔ a systematic problem solving approach toward providing
individualized nursing care.
What is NANDA-I✔✔ North American Nursing
Diagnosis Association International
What are the characteristics of the nursing process?✔✔ 1-framework for care to indiv,
families, & communities 2-orderly & systematic 3-interdependent 4-provides specific care
for the indiv, fam, & comm 5- client centered 6-appropriate for use throughout lifespan 7-
used in ALL settings
What are the steps of the nursing process?✔✔ ADPIE A=assessment D=diagnosis
P=planning I=implementation E=evaluation
How does the nurse obtain assessment info?✔✔ 1- initial (or admission assessment) 2-
focused assessment 3- emergency assesment
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
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.
focused assessment questions✔✔ - What are your symptoms?
- When did they start?
- What activity were you doing ?
- What makes it better or worse?
- What are you doing to relieve the symptom?
Emergency assessment✔✔ Performed to identify a life-threatening problem (choking, stab
wound, heart attack).
subjective data✔✔ Information verbalized or stated by the client.
objective data✔✔ - Observable and measurable information.
- Remember to include your senses: smell, hearing, touch and sight.
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.")
signs are✔✔ objective
symptoms are✔✔ subjective
2 sources of data✔✔ primary & 2ndary
, primary source of data✔✔ -Information obtained from the patient (only)
secondary sources of data✔✔ - 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.
Data is 1,2,3✔✔ collected, validated, then clustered
clustering of data often contains✔✔ defining characteristics which are specific assessment
findings that support a
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 sources of data for obtaining information from the client✔✔ subjective & objective,
primary & secondary, people, healthcare professionals, medical chart, test & lab results etc
identify how you develop a nursing diagnosis✔✔ As you cluster data, you begin to consider
various diagnoses that may relate to the client. You must remember that if certain defining
characteristics do not exist for a specific diagnosis, then you must not use the diagnosis.
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.
what is the difference between a medical and nursing dx✔✔ A medical diagnosis describes
a disease process. A nursing diagnosis describes an individual, family or
group response to an actual or potential problem.
medical dx✔✔ -Identification of a disease condition based on specific
findings such as diagnostic tests and procedures.
- Remains the same as long as the disease is present.
nursing dx✔✔ - Clinical judgment in response to actual or potential
health problems.
