purpose is to identify and solve a patients problem (Base of
Nursing Process nursing)
Phase 1: Assessment-gathering information
Phase 2: Nursing diagnosis- analysis and identification of an
actual or potential problem
Phase 3: Planning- goals and outcomes
Phase 4: Implementing- following through with decided plan
Nursing Process of action
Phase 5: Evaluation- to see if goals/outcomes have been met
Is the end product of the nursing process, individualized for
Care Plan the patient
Actual- actively having the problem (1. Diagnostic label, 2.
Actual Nursing Diagnosis Related to, 3. As evidence by)
Potential- risk for has not happened but could pose a problem
for the patient later ( Diagnostic statement...risk for nursing
Potential Nursing Diagnosis diagnosis, related to cause of problem)
the cause, set of causes, or manner of causation of a disease
Etiology or condition
P= problem
E= etiology (cause)
S= symptoms (evidence)
If the etiology is incorrect then the nursing interventions will
be ineffective.
How to write a nursing Etiology can change even if the nursing diagnosis is the
diagnosis (statement) same, for example: ineffective breathing pattern can be
related to fatigue and anxiety
The nursing diagnosis drives interventions and patient
Why do we develop a nursing outcomes, enabling the nurse to develop the patient care plan
diagnosis?
, The RN
Who is responsible for the
nursing diagnosis?
The RN
Who initiates the patient plan
of care?
Obtain patient health history
Prioritization
General assessment
Neurological
Cardiovascular
Pulmonary
Assessment (Including 60 Integumentary
second assessment) Gastrointestinal
Genitourinary
Pain
Are errors in medical care that are clearly identifiable,
preventable, and serious in their consequences for patients,
Never Events and that indicates a real problem in the safety and credibility
of a health care facility.
The purpose of National Is to improve patient safety, the goals focus on problems in
Patient Safety Goals health care safety and how to solve them
Is an undesirable situation or condition the affects a patient
Hospital Acquired Conditions and that arose during a stay in a hospital or medical facility.
(HACs)
Are measures and indicators that reflect the structure,
Nurse Sensitive Indicators
processes and outcomes of nursing care.
(NSIs)
The ability to make logical, rational decisions and decide
Clinical Judgement whether a given action is right or wrong.
The most effective measures are using sterile technique, hand
hygiene, patient education, use of PPE.
Infection Prevention
Outcomes from medical care that are important to the patient
Patient Centered Outcomes
Nursing Process nursing)
Phase 1: Assessment-gathering information
Phase 2: Nursing diagnosis- analysis and identification of an
actual or potential problem
Phase 3: Planning- goals and outcomes
Phase 4: Implementing- following through with decided plan
Nursing Process of action
Phase 5: Evaluation- to see if goals/outcomes have been met
Is the end product of the nursing process, individualized for
Care Plan the patient
Actual- actively having the problem (1. Diagnostic label, 2.
Actual Nursing Diagnosis Related to, 3. As evidence by)
Potential- risk for has not happened but could pose a problem
for the patient later ( Diagnostic statement...risk for nursing
Potential Nursing Diagnosis diagnosis, related to cause of problem)
the cause, set of causes, or manner of causation of a disease
Etiology or condition
P= problem
E= etiology (cause)
S= symptoms (evidence)
If the etiology is incorrect then the nursing interventions will
be ineffective.
How to write a nursing Etiology can change even if the nursing diagnosis is the
diagnosis (statement) same, for example: ineffective breathing pattern can be
related to fatigue and anxiety
The nursing diagnosis drives interventions and patient
Why do we develop a nursing outcomes, enabling the nurse to develop the patient care plan
diagnosis?
, The RN
Who is responsible for the
nursing diagnosis?
The RN
Who initiates the patient plan
of care?
Obtain patient health history
Prioritization
General assessment
Neurological
Cardiovascular
Pulmonary
Assessment (Including 60 Integumentary
second assessment) Gastrointestinal
Genitourinary
Pain
Are errors in medical care that are clearly identifiable,
preventable, and serious in their consequences for patients,
Never Events and that indicates a real problem in the safety and credibility
of a health care facility.
The purpose of National Is to improve patient safety, the goals focus on problems in
Patient Safety Goals health care safety and how to solve them
Is an undesirable situation or condition the affects a patient
Hospital Acquired Conditions and that arose during a stay in a hospital or medical facility.
(HACs)
Are measures and indicators that reflect the structure,
Nurse Sensitive Indicators
processes and outcomes of nursing care.
(NSIs)
The ability to make logical, rational decisions and decide
Clinical Judgement whether a given action is right or wrong.
The most effective measures are using sterile technique, hand
hygiene, patient education, use of PPE.
Infection Prevention
Outcomes from medical care that are important to the patient
Patient Centered Outcomes
