Nursing Process and Documentation

Question 1

5 Steps of the Nursing Process

Answer 1

1. Assessment; collecting, organizing, and verifying pt data-observation, interview, px examination
2. Diagnosis; interpreting assessment data and identifying client strength and problems- “impaired physical mobility related to acute pain as manifested..”
3. Planning; involves decision making and problem solving- “establish priorities according to importance and time; highest is life threatenint”
4. Implementation; putting the nursing care plan into action-“direct and indirect”
5. Evaluation; evaluating client responses-ongoing process- “are nursing interventions effective in meeting outcomes?”

Question 2

Making a nursing diagnostic statement

Answer 2

Use PES (Problem + Etiology; related factors + Signs/Symptoms)

Example:

Constipation r/t insufficient physical activity e/b client stating he has not had a bowel movement in a few days and his normal bowel pattern is a daily bowel movement.

Start with ‘S’ for diagnosis- data that hints at the problem.

Question 3

Making a risk nursing diagnosis

Answer 3

No evidence as it hasn't been witnessed yet. 
Use PE (Problem + Etiology)

Example:

Risk for constipation r/t insufficient physical activity.

Question 4

Medical vs Nursing Diagnoses

Answer 4

• Medical practitioners are taught to diagnose, prescribe, and treat pathophysiological conditions (diseases)
• Nurses are taught to take a more holistic approach- to examine actual or potential alterations in health states, whether they are disease related or not. (how pt responds to medical problems, treatment plans, etc)