1. THE NURSING PROCESS
A systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness.
A systematic way to plan, implement and evaluate care for individuals, families, groups and communities.

2. Characteristics of the Nursing Process
Dynamic
Client-centered
Planned
Interpersonal and collaborative
Universally applicable
Can focus on problems or strengths

3. ASSESSMENT Collect, organize, validate data
Obtain information from charts, client, family
Data gathering (no conclusions)
Establish information about person’s response to health concerns and ability to manage

4. DATA COLLECTION Observation Interview Types of questions Setting
Rapport
Examination

5. DIAGNOSIS Sort, cluster, analyze information
Identify potential problems and strengths
Write statement of problem or strength
Risk of infection related to compromised nutrition
Potential for effective breastfeeding related to knowledge level and support system
Prioritize the problems
Not a medical diagnosis

6. TYPES OF DIAGNOSIS Actual diagnosis – problem is present
Risk nursing diagnosis
Possible diagnosis
Wellness diagnosis

7. PLANNING
Establish the goals, interventions and outcomes

8. IMPLEMENTATION Carry out the plan
Assist person to meet goals; facilitate coping
Continue to collect data
Document care

9. EVALUATION Determine if goals were met Should care continue
Modify plan if necessary

10. Benefits of using the nursing process
Continuity of care
Prevention of duplication
Individualized care
Increased client participation
Collaboration of care
Standards of care

11. NANDA – North American Nursing Diagnosis Association
Identifies nursing functions
Creates classification system
Establishes diagnostic labels
Risk of infection related to compromised nutritional state
Potential complication of seizure disorder related to medication compliance

12. Creating nursing diagnosis statements
State the person’s response or diagnostic label
Identify related factors contributing to or causing the problem
Signs and symptoms

13. Qualities for application of the nursing process
Intellectual skills
Critical thinking
Decision-making
Interpersonal skills
Technical skills
Creativity
Adaptability