This documents provide a comprehensive overview of the Nursing Process and the role of Critical Thinking in nursing practice. They are organized into clear sections covering the five key steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation, each accompanied by concise explanations...
The nursing process is a systematic approach that guides nurses in delivering patient care, ensuring
consistency and quality. It consists of five essential steps:
Assessment:
The first step involves collecting comprehensive data about the patient's health status. This includes
subjective data (patient's verbal report of symptoms) and objective data (measurable factors like
temperature, pulse, and lab results). Nurses gather information through physical exams, medical
histories, and patient interviews.
Diagnosis:
This step is about identifying the patient's health problems based on the data collected during the
assessment. Unlike medical diagnoses, nursing diagnoses focus on patient responses to illness (e.g.,
“ineffective airway clearance,” “acute pain”).
Planning:
Nurses establish measurable and realistic goals to address the patient's diagnosis. Care plans are
developed to outline interventions that will help achieve these goals. The planning process ensures that
care is specific and tailored to the patient’s needs.
Implementation:
The plan is put into action. Nurses carry out interventions such as administering medication, providing
wound care, educating the patient, or collaborating with other healthcare professionals. The goal is to
achieve the outcomes identified in the planning phase.
Evaluation:
After interventions are performed, nurses assess their effectiveness. If the patient's goals are not being
met, adjustments to the care plan are made. This step ensures the care provided is continually
improving based on patient progress.
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