The Nursing Process

5 step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating.

Systematically and continuously collect, validate, and communicate patient data.

Analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve.

Observation of the patient to demonstrate the resolution of the problems identified by the nursing diagnoses and general problem list, along with the time frame for accomplishing these outcomes.
Establish patient goals to prevent, reduce, or resolve the problems identified in the nursing diagnoses and determination of related nursing interventions.

Carry out the plan of care.

Measurement of the extent to which the patient has achieved the goals specified in the plan of care; factors that positively or negatively influence goal achievement are identified, and the plan of care is terminated or revised.

Thought that is disciplined, comprehensive, based on intellectual standards, and, as a result, well-reasoned; a systematic way to form and shape one's thinking that functions purposefully and exactingly.

Set of concepts, along with the statements that arrange the concepts into an understandable pattern.

Comprehensive nursing assessment resulting in baseline data that enables the nurse to make a judgement about a patients health status, ability to manage his or her own healthcare, and need for nursing, and to plan individualized, holistic healthcare for the patient.

Assessment conducted to assess a specific problem; focuses on pertinent history and body regions.

Rapid focused assessment conducted to determine potentially fatal situations.

An assessment that is scheduled to compare a patient's current status to baseline data obtained earlier.

Information perceived only by the affected person.

Information perceptible to the senses; may be verified by another person.

Act of confirming and verifying.