Nursing Process steps
Assessment, Diagnosis, Planning, Intervention, Evaluation
Assessment
gather patient data through observation, interview, and physical assessment
Diagnosis
analyze, validate, and cluster patient data to id patient problems
Planning
prioritize nursing diagnosis and id short and long term goals
Implementation
initiate specific nursing interventions and treatments to achieve goals
Evaluation
Determine whether goals are met or should be revised
Primary Data
information obtained directly from patient
Secondary Data
information collected from family, friends, community, HCP