NURSING PROCESS

by: one of our best professor in NCM (Mrs. Cubon, RN, MAN)
The term NURSING PROCESS was first used/mentioned by Lydia Hall, a nursing theorist, in 1955 wherein she introduced 3 STEPs: observation, administration of care and validation.
Since then, nursing process continue to evolve: it used to be a 3-step process, then a 4-step process (APIE), [...]

EVALUATION

is assessment the client’s response to nursing interventions and then comparing that response to predetermined standards or outcome criteria.

Purpose: To appraise the extent to which goals and outcome criteria of nursing care have been achieved.
Activities:

Collect data about the client’s response.
Compare the client’s response to goals [...]

IMPLEMENTATION

is putting the nursing care plan into action.

Purpose: To carry out planned nursing interventions to help the client attain goals and achieve optimal level of health.
Activities:

Reassessing – to ensure prompt attention to emerging problems.
Set priorities – to determine the order in which nursing interventions [...]

Planning

involves determining before and the strategies or course of actions to be taken before implementation of nursing care. To be effective, the client and his family should be involve in planning.

Purpose:

To determine the goals of care and the course of actions to be undertaken during [...]

Outcome Identification

refers to formulating and documenting measurable, realistic and client-focused goals that will provide the basis for evaluating nursing diagnosis.

Purposes:

To provide individualized care
To promote client participation
To plan care that is realistic and measurable
To [...]

Diagnosis - Second Step in the Nursing Process

Diagnosing

is the 2nd step of the nursing process.
the process of reasoning or the clinical act of identifying problems

Purpose: To identify health care needs and prepare a Nursing Diagnosis.
To diagnose in nursing: it means to analyze assessment information and derive meaning from this analysis.
Nursing Diagnosis

is a statement of a client’s potential or actual health problem resulting [...]

Assessment - First Step in the Nursing Process

it is systematic and continuous collection, validation and communication of client data as compared to what is standard/norm.
it includes the client’s perceived needs, health problems, related experiences, health practices, values and lifestyles.

Purpose: To establish a [...]