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The Nursing Process
Transcript of The Nursing Process
Nursing 225 Project * Spring 2013 Nursing Process ASSESSMENT Subjective: What your patient tells you.
Objective: Your observations in assessment,
interview, and from the records. DIAGNOSIS Your Nursing Diagnosis will be
Two Parts if Actual Dx
or Three Parts Risk Dx PLANNING IMPLEMENTATION EVALUATION "Evaluation is an ongoing process that occurs whenever you have contact with a patient" ACTUAL
Diagnosis Signs and Symptoms
"As Evidenced By" Etiology
"Related To" RISK
"Related To" Planning
Outcomes Long-Term Outcome
LTO Short-Term Outcome
STO 2. Revision of Nursing Diagnosis! 3. Revision of
Outcomes & Interventions! Outcomes & Interventions "Describes a human response to health conditions or life processes that may develop in a vulnerable individual." (the CAUSE of the NDx) 2-PART + 1. Re-Assessment! Evaluation leads you back to: "Describes human response to health conditions or life processes that exist. " 3-PART + + NDx is REVERSE of LTO "the Etiology must be within the domain of nursing practice and be a condition that responds to nursing interventions" (Potter & Perry, p. 229) (Potter & Perry, p. 227) (Potter & Perry, p. 228) the CAUSE of the NDx NDx is REVERSE of LTO the defining characteristics: subjective or objective Patient-Centered
Goal of Interventions LTO is REVERSE of NDx "Patient will......................
by...(specific date)............." achieved by Interventions Many STOs may be necessary to achieve our LTO! "Patient will....................
by.....(specific date)........" Interventions are HOW you'll achieve your OUTCOMES! Interventions address STOs. "Nurse will....................
by......(specific time)...." Interventions include
a RATIONALE--the evidence
or research that supports
the intervention. Your FIRST intervention is ALWAYS to ASSESS. Hooray! You finally get to GIVE some Nursing CARE! This is where you carry out or delegate your INTERVENTIONS. (Potter & Perry, p. 266) Have your outcomes been:
Not Met? if your outcome has been met, discontinue your care plan. If not, you will continue care. Re-ASSESS & REVISE 1 2 3 4 5