Nurse Assessment is the first step of the nursing process. We can view this step as an interview process in which the nurse is trying to gather information from the patient. This information is gathered by two steps, observation and asking specific questions. This helps the nurse get a better understanding of the patient’s physiological, psychological, sociological and spiritual status. Physiologically the nurse is looking for motor and sensory nerve functions, rest, sleep activity, skin color, vital signs, allergies, drug use, signs of physical abuse and any chronic conditions. Psychological, Socialogical and spiritually the nurse is looking for emotional tone, occupation, family ties, financial support, and responsibilities. In gathering all this information it helps the nurse” analyze the data as a basis for developing nursing diagnoses, identifying collaborative problems, and developed and individualized care plan for that patient.”
Nursing Diagnosis is the overall observation from the nurse’s point of view. This is when the nurse determines actual or potential problems. This potential problem would of have been based on the assessment of the clinical situation. During diagnosis the nurse must organized her observations (data) and compare data to standards. The nurse must be able to identify gaps and inconsistencies in data. Determine the client’s health problems, risk and strengths. A nurse cannot diagnose a medical condition only the doctor can, but she can identify a potential problem and example of this would be. “The patient is not eating properly; he/she is only eating once a day.”
Nursing Planning requires critical thinking. Planning involves determining beforehand the strategies or course of... [continues]
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