Nursing Process: A Systematic Approach to
Individualized Care
This outline provides a comprehensive and quality overview of the nursing
process.
1. Defining the Nursing Process: The nursing process is a systematic,
problem-solving approach utilized by nurses to provide individualized
and holistic nursing care. It is a cyclical and dynamic framework that
guides nursing practice.
2. NANDA-I Explained: NANDA-I stands for the North American Nursing
Diagnosis Association International. It is a professional organization
responsible for developing, refining, and promoting a standardized language
for nursing diagnoses.
3. Key Characteristics of the Nursing Process: The nursing process is
characterized by being:
o A framework for providing care to individuals, families, and
communities.
o Orderly and systematic, following a logical sequence of steps.
o Interdependent, with each step influencing and being influenced by
the others.
o Focused on providing specific and individualized care tailored to the
unique needs of the client, family, or community.
o Client-centered, with the client actively involved in their care.
o Appropriate for use throughout the lifespan, adapting to the
developmental stages and needs of individuals.
, o Used in all healthcare settings, providing a consistent approach to
care.
4. The Five Steps of the Nursing Process (ADPIE): The nursing process
consists of five sequential and interrelated steps:
o Assessment: Collecting and organizing data about the client.
o Diagnosis: Analyzing the assessment data to identify nursing
diagnoses.
o Planning: Developing a plan of care that prescribes nursing strategies
to achieve expected outcomes.
o Implementation: Carrying out the nursing interventions identified in
the plan of care.
o Evaluation: Determining the effectiveness of the nursing interventions
and the extent to which client goals and expected outcomes have been
met.
5. Methods of Obtaining Assessment Information: Nurses gather assessment
data through various types of assessments:
o Initial Assessment (or Admission Assessment): A comprehensive
data collection performed upon the client's entry into the healthcare
system to establish a baseline.
o Focused Assessment: A brief data collection centered on a specific
problem or the client's current condition.
o Emergency Assessment: A rapid and focused data collection
conducted to identify life-threatening problems.
6. Comprehensive Data Collection Components: A thorough assessment
involves gathering information about:
o Past medical history: Previous illnesses, treatments, and health
conditions.
, o Family history: Health conditions prevalent in the client's family.
o Reason for admission: The primary health concern that led to the
client's seeking care.
o Current medications: All prescribed and over-the-counter
medications, including dosages, routes, and frequency.
o Previous hospitalizations and surgeries: Dates, reasons, and
outcomes.
o Psychosocial assessment: Information about the client's mental,
emotional, social, and spiritual well-being, coping mechanisms, and
support systems.
o Nutrition: Dietary intake, preferences, and any nutritional concerns.
o Complete physical assessment: A systematic examination of all
body systems.
7. In-depth Look at Focused Assessment: A focused assessment is a targeted
data collection that:
o Collects data specifically about a problem that has already been
identified.
o Determines the current status of the problem, including whether it
still exists and if there have been any changes.
8. Key Questions for a Focused Assessment: To gather pertinent information
during a focused assessment, nurses often ask:
o What are your current symptoms?
o When did these symptoms first start?
o What activity were you doing when the symptoms occurred?
o What makes your symptoms better or worse?
o What have you been doing to try and relieve the symptom?
Individualized Care
This outline provides a comprehensive and quality overview of the nursing
process.
1. Defining the Nursing Process: The nursing process is a systematic,
problem-solving approach utilized by nurses to provide individualized
and holistic nursing care. It is a cyclical and dynamic framework that
guides nursing practice.
2. NANDA-I Explained: NANDA-I stands for the North American Nursing
Diagnosis Association International. It is a professional organization
responsible for developing, refining, and promoting a standardized language
for nursing diagnoses.
3. Key Characteristics of the Nursing Process: The nursing process is
characterized by being:
o A framework for providing care to individuals, families, and
communities.
o Orderly and systematic, following a logical sequence of steps.
o Interdependent, with each step influencing and being influenced by
the others.
o Focused on providing specific and individualized care tailored to the
unique needs of the client, family, or community.
o Client-centered, with the client actively involved in their care.
o Appropriate for use throughout the lifespan, adapting to the
developmental stages and needs of individuals.
, o Used in all healthcare settings, providing a consistent approach to
care.
4. The Five Steps of the Nursing Process (ADPIE): The nursing process
consists of five sequential and interrelated steps:
o Assessment: Collecting and organizing data about the client.
o Diagnosis: Analyzing the assessment data to identify nursing
diagnoses.
o Planning: Developing a plan of care that prescribes nursing strategies
to achieve expected outcomes.
o Implementation: Carrying out the nursing interventions identified in
the plan of care.
o Evaluation: Determining the effectiveness of the nursing interventions
and the extent to which client goals and expected outcomes have been
met.
5. Methods of Obtaining Assessment Information: Nurses gather assessment
data through various types of assessments:
o Initial Assessment (or Admission Assessment): A comprehensive
data collection performed upon the client's entry into the healthcare
system to establish a baseline.
o Focused Assessment: A brief data collection centered on a specific
problem or the client's current condition.
o Emergency Assessment: A rapid and focused data collection
conducted to identify life-threatening problems.
6. Comprehensive Data Collection Components: A thorough assessment
involves gathering information about:
o Past medical history: Previous illnesses, treatments, and health
conditions.
, o Family history: Health conditions prevalent in the client's family.
o Reason for admission: The primary health concern that led to the
client's seeking care.
o Current medications: All prescribed and over-the-counter
medications, including dosages, routes, and frequency.
o Previous hospitalizations and surgeries: Dates, reasons, and
outcomes.
o Psychosocial assessment: Information about the client's mental,
emotional, social, and spiritual well-being, coping mechanisms, and
support systems.
o Nutrition: Dietary intake, preferences, and any nutritional concerns.
o Complete physical assessment: A systematic examination of all
body systems.
7. In-depth Look at Focused Assessment: A focused assessment is a targeted
data collection that:
o Collects data specifically about a problem that has already been
identified.
o Determines the current status of the problem, including whether it
still exists and if there have been any changes.
8. Key Questions for a Focused Assessment: To gather pertinent information
during a focused assessment, nurses often ask:
o What are your current symptoms?
o When did these symptoms first start?
o What activity were you doing when the symptoms occurred?
o What makes your symptoms better or worse?
o What have you been doing to try and relieve the symptom?
