University:
University of North Carolina at Chapel Hill
Course:
NURS 110 | Introduction to Nursing
Academic year:

2024
Views:

359

Pages:

2
Author:

Amelia R.

Amelia Roses (UNC2021-5678) Bachelor of Science in Nursing LECTURE NOTES ON THE NURSING PROCESS The nursing process is a systematic method used by nurses to provide individualized, holistic care to patients. It consists of five essential steps: assessment, nursing diagnosis, planning, implementation, and evaluation. Understanding each step is fundamental to delivering effective and efficient nursing care. 1. Assessment: a. Assessment is the first step of the nursing process and involves gathering comprehensive data about the patient's health status, needs, and preferences. b. Data collection methods include interviews, physical examinations, observation, and review of medical records. c. Assessment provides the foundation for identifying actual and potential health problems and determining the patient's response to illness or treatment. 2. Nursing Diagnosis: a. Nursing diagnosis involves analyzing the assessment data to identify actual or potential health problems and formulate nursing diagnoses. b. Nursing diagnoses are clinical judgments about the patient's response to actual or potential health problems. c. They are derived from standardized nursing terminologies and provide the basis for planning individualized nursing care. 3. Planning: a. Planning is the process of developing a comprehensive care plan based on the nursing diagnoses and patient goals. b. Goals and outcomes are established collaboratively with the patient and are specific, measurable, attainable, relevant, and time-bound (SMART). c. Interventions are selected to achieve the identified goals and may include nursing actions, patient education, and coordination of care with other healthcare providers. 4. Implementation: a. Implementation involves executing the care plan by implementing the selected nursing interventions. b. Nursing interventions are based on evidence-based practice, clinical expertise, and patient preferences. c. Nurses deliver direct care, coordinate services, provide health education, and advocate for patients' needs during the implementation phase. 5. Evaluation: a. Evaluation is the final step of the nursing process and involves assessing the patient's response to nursing interventions and progress towards goal achievement. b. Evaluation criteria are used to measure the effectiveness of interventions and determine if goals and outcomes have been met. c. Based on the evaluation findings, the care plan may be revised, continued, or discontinued to meet the patient's changing needs. Importance of the Nursing Process: a. Promotes systematic and organized patient care delivery. b. Facilitates critical thinking and clinical decision-making. c. Enhances communication and collaboration among healthcare team members. d. Provides a framework for individualized and evidence-based nursing practice. e. Improves patient outcomes and satisfaction with care. The nursing process is a systematic approach that guides nurses in delivering high-quality, patient-centered care. By understanding and applying the steps of assessment, nursing diagnosis, planning, implementation, and evaluation, nurses can effectively address the complex healthcare needs of patients across various settings and populations