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Using the nursing pr
Using the nursing process
| Term | Definition |
|---|---|
| Collect info about the client. | Data collection is the basis for identifying problems. |
| Analyze the data for what is normal and abnormal. | Abnormalities provide clues to the clients problems. |
| Identify problem-focused, risk, syndrome, and health promotion nursing dx and collaborative problems. | Problem identification directs the nurse to select methods for maintaining or restoring the client's health. |
| Prioritize the problem list. | Setting priorities targets problems that require the most immediate attention. |
| Establish specific criteria for evaluating whether the problems have been prevented, reduced or resolved. | Goals predict the expected outcomes from nursing care. |
| Select a limited number of appropriate nursing interventions. | The nurse uses evidence based knowledge to determine which measures will be most effective in accomplishing the goals of care. |
| Give specific directions for nursing care. | Specific directions promote consistency and continuity among caregivers. |
| Document the plan for care using whatever format is acceptable. | A documented plan provides a means of communication and reference for the nursing team to follow. |
| Discuss the plan with nursing team members, the client, and the family. | Verbally sharing the plan ensures that everyone is informed and goal directed. |
| Put the plan into action. | Work produces results. |
| Observe the client's responses. | Evaluating outcomes is the basis for determining the effectiveness of the plan of care. |
| Chart all nursing activities and the client's responses. | Documentation demonstrates that planned care has been implemented and provides info about the client's progress. |
| Compare the client's responses with the outcome criteria. | If the planned care is appropriate, there should be some measure of progress toward accomplishing goals. |
| Discuss the progress, or lack of it, with client, family and other nursing team members. | Pooling resources may provide better alternatives when revising the plan of care. |
| Change the plan in areas that are no longer appropriate. | The nursing care plan changes according to the needs of the client. |
| Continue to implement and evaluate the revised plan of care. | The nursing process is continuous; it is repeated until the goals have been met. |
Created by:
Jessica Venyke
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