Nursing Process

A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes.

• Actual nursing diagnoses
• "risk for" nursing diagnoses
• wellness nursing diagnoses (pt healthy, want to keep that way)
• collaborative problems

• Label
• definition
• defining characteristics
• related factors
• risk factors

• •Constipation related to inadequate fluid intake
• •Ineffective individual coping related to fear of medical diagnosis
• •Risk for impaired skin integrity related to immobility

• 1. establish priorities
•   - threats to physiological integrity
•   - the health care setting
•   - client's perception of need
•   - client's self-care ability
• 2. establish outcomes
•   - defining outcomes: measurable and realistic
•   - types of outcomes: nursing-sensitive client outcome
•   - nursing outcomes classification (NOC) system

• client-centered
• singular goal or outcome
• observable
• measurable
• time-limited
• mutual factors
• realistic

• teaching
• collaborating
• managing (you can delegate activity, but not accountability)
• coordinating
• monitoring
• assisting
• supporting
• protecting
• sustaining

• direct care nursing intervention
• indirect care nursing intervention
• nurse-initiated intervention
• physician-initiated intervention

• who (provides the care)
• what (the care required to meet the need)
• where (home, hospital, or clinic)
• when (time delivered/sequence of events)
• why (rationale)
• how (method; individualizes a client's care(

• active listening
• emotional support
• infection control and protection
• vital signs monitoring
• medication management

• cognitive
• interpersonal
• psychomotor

• goals met
• goals partially met
• goals not met