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Nursing Process: Assessment to Evaluation

The document outlines the components and purposes of the nursing process which includes assessing, diagnosing, planning, implementing, and evaluating. The assessing component involves establishing a database about the client's health history and needs by collecting, organizing, and validating client data. The diagnosing component identifies client strengths and health problems by analyzing and synthesizing the collected data to form nursing diagnoses and collaborative problem statements. The planning component develops an individualized care plan by determining goals and nursing interventions in collaboration with the client and other health professionals.

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kate
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16 views2 pages

Nursing Process: Assessment to Evaluation

The document outlines the components and purposes of the nursing process which includes assessing, diagnosing, planning, implementing, and evaluating. The assessing component involves establishing a database about the client's health history and needs by collecting, organizing, and validating client data. The diagnosing component identifies client strengths and health problems by analyzing and synthesizing the collected data to form nursing diagnoses and collaborative problem statements. The planning component develops an individualized care plan by determining goals and nursing interventions in collaboration with the client and other health professionals.

Uploaded by

kate
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Component and Purpose Activities

Description

Assessing To establish a database Establish a database:


about the client’s
Collecting, organizing,  Obtain a nursing health history
response to health
validating, and
concerns or illness and  Review client records
documenting client data
the ability to manage
 Review nursing literature
health care needs
 Consult support persons

 Consult health professionals

Update data as needed

Organize data

Validate data

Communicate/document data

Diagnosing To identify client Interpret and analyze data:


strengths and health
Analyzing and  Compare data against standards
problems that can be
synthesizing data
prevented or resolved by  Cluster or group data (generate tentative
collaborative and hypotheses)
independent nursing
interventions.  Identify gaps and inconsistencies

To develop a list of Determine client’s strengths, risks, and problems


nursing diagnoses and Formulate nursing diagnoses and collaborative
collaborative problems. problem statements

Planning To develop and Set priorities and goals/outcomes in collaboration


individualized care plan with client
Determining how to
that specifies client
prevent, reduce, or Write goals/desired outcomes
goals/desired outcomes
resolve the identified
and related nursing Select nursing strategies/interventions
client problems; how to
interventions.
support client strengths; Consult with other health professionals
and how to implement
nursing interventions in Write nursing orders and nursing care plan
an organized, Communicate care plan to relevant healthcare
individualized, and goal- providers
directed manner

Implementing To assist the client to Reassess the client to update the database
meet desired
Carrying out the goals/outcomes; Determine need for nursing assistance
planned nursing promote wellness and
Perform or delegate planned nursing interventions
interventions disease; restore health;
and facilitate coping with Communicate what nursing actions were
altered functioning. implemented:

 Document care and client responses to care

 Give verbal reports as necessary

Evaluating To determine whether to Collaborate with client and collect data related to
continue, modify, or desired outcomes
Measuring the degree
terminate the plan of
to which Judge whether goals/outcomes have been achieved
care.
goals/outcomes have
Relate nursing actions to client outcomes
been achieved and
identifying factors that Make decisions about problem status
positively or negatively
influence goal Review and modify the care plan as indicated or
achievement terminate nursing care

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