Module 4 – Clinical Judgement and Nursing Process
The nursing process consists of 5 steps.
1. Assessment if the first step. Data is collected during this step so that the rest of the nursing
process may be efficient
...
Module 4 – Clinical Judgement and Nursing Process
The nursing process consists of 5 steps.
1. Assessment if the first step. Data is collected during this step so that the rest of the nursing
process may be efficiently carried out.
Nursing assessments focus on the patient’s responses to health problems, not the data
based from the patient’s diagnosis.
Initial Assessment – preformed by the nurse shortly after the patient is admitted to a
facility. This assessment typically follows the guidelines set by the standards of the
facility and establishes a baseline database for the patient. Allows the nurse to gather
health data and identify health problems to set priorities for further focused
assessments.
Focused Assessment – Nurse gathers data about a problem that has already been
identified.
What are your signs and symptoms?
When did they first start?
What makes it better/worse?
Emergency Assessment – Done when a psychological or physiological crisis occurs to
identify what life-threatening problems are occurring.
Time-Lapsed Assessment - This is a scheduled assessment to compare a patient’s current
condition with their baseline condition. Most residents in long-term health care have
time-lapsed assessments scheduled periodically.
Priorities to set during assessment include health orientation, developmental stage,
culture and the patients need for nursing.
Always validate assessment data before using it for diagnosing.
2. Diagnosis is the second step. Data gathered from the assessment are utilized to form a
judgement about the patients’ health. The purposes of diagnosing are:
Identify how a person, group, community, responds to an actual or potential
health and life process.
Identify the factors that contribute to or cause the health problems.
Identify resources and strengths that that person or community can draw on to
help resolve or prevent the problem.
During the diagnosing step of the nursing process the nurse clarifies the exact nature of
the patient’s problems and risks that must be addressed to achieve the patient’s
outcome of care. Conclusions made during this step affects selected interventions and
the entire plan of care.
NANDA – North American Nursing Diagnosis Association.
“Nursing diagnosis is a clinical judgement about personal, family or community
responses to actual or potential health problems/life processes. Nursing
diagnosis provides the basis of selecting nursing interventions to achieve
outcomes for which the nurse is accountable.”
Nursing diagnoses are written to describe patient problems that the nurse can treat
independently.
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