In 1980, The American Nurses’ Association defined nursing as “The diagnosis and treatment of human responses to actual or potential health problems.” The practices (steps) of the nursing
process lapping
including assessment, diagnosis, plan, implementation, and evaluation are cyclic, over- and interrelated.
• Step 1, assessment, is the most critical step and answers the questions: “What is happen- ing (i.e., actual problem)?”, or “What could happen (i.e., potential problem)?” This step involves collecting, organizing, and analyzing information/data about the patient. That is two parts: data collection and data analysis. In general, the data collection is a holistic approach and the methods of data collection can be observation, interview, and examina- tion. The data types include subjective and objective data. The former can be “symp- toms” that the patient describes; e.g. “I can’t do anything for myself.” The later can be “signs” that can be observed, measured, and verified; e.g., swollen joints.
• Step 2, diagnosis, is a statement that describes a specific human response to an actual or potential health problem that requires nursing intervention.
• Step 3, plan, provides consistent, continuous care that will meet the patient’s unique needs, includes patient goals and nursing orders. The patient goals are directly related to the patient’s problem as stated in the diagnosis, which describe the desired result of nurs- ing care and the nursing order describes what the nurse will do to help the patient achieve the goals.
• Step 4, implementation, involves applying the skills needed to implement the nursing or- der. The major tasks include reassessing the patient, validating that the care plan is accu- rate, carrying out nurses’ orders, documenting on patient’s chart and so forth.
• Step 5, evaluation, compare the patient’s current status with the stated patient goals and has three different operations or purposes: evaluation of the quality of the written care plan, evaluation of the client’s progress, and evaluation of the status/currency of the care plan.
Nursing practices are increasingly being encoded in the form of nursing guidelines and protocols that drive health care service delivery. Nurses especially use the health care knowledge combined with their know-how and experience to deliver health care services. Today, this work can be en- hanced by enabling technologies such as a KMS.
In 1980, The American Nurses’ Association defined nursing as “The diagnosis and treatment of human responses to actual or potential health problems.” The practices (steps) of the nursingprocess lappingincluding assessment, diagnosis, plan, implementation, and evaluation are cyclic, over- and interrelated.• Step 1, assessment, is the most critical step and answers the questions: “What is happen- ing (i.e., actual problem)?”, or “What could happen (i.e., potential problem)?” This step involves collecting, organizing, and analyzing information/data about the patient. That is two parts: data collection and data analysis. In general, the data collection is a holistic approach and the methods of data collection can be observation, interview, and examina- tion. The data types include subjective and objective data. The former can be “symp- toms” that the patient describes; e.g. “I can’t do anything for myself.” The later can be “signs” that can be observed, measured, and verified; e.g., swollen joints.• Step 2, diagnosis, is a statement that describes a specific human response to an actual or potential health problem that requires nursing intervention.• Step 3, plan, provides consistent, continuous care that will meet the patient’s unique needs, includes patient goals and nursing orders. The patient goals are directly related to the patient’s problem as stated in the diagnosis, which describe the desired result of nurs- ing care and the nursing order describes what the nurse will do to help the patient achieve the goals.• Step 4, implementation, involves applying the skills needed to implement the nursing or- der. The major tasks include reassessing the patient, validating that the care plan is accu- rate, carrying out nurses’ orders, documenting on patient’s chart and so forth.• Step 5, evaluation, compare the patient’s current status with the stated patient goals and has three different operations or purposes: evaluation of the quality of the written care plan, evaluation of the client’s progress, and evaluation of the status/currency of the care plan.Nursing practices are increasingly being encoded in the form of nursing guidelines and protocols that drive health care service delivery. Nurses especially use the health care knowledge combined with their know-how and experience to deliver health care services. Today, this work can be en- hanced by enabling technologies such as a KMS.
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