Five Steps of the Nursing Process

1. Assessment

2. Diagnosis

3. Planning

4. Implementation

5. Evaluation

Assessment

• Gathering info to develop a database, or record, from which all nursing process plans develop

• Requires skill and expertise of the nurse

Two types of Assessment datas:

• Subjective data

• Objective data

* It is very important to get subjective & objective assessment data when the PT is first seen or on admission to the hospital (hosp).

Subjective Data

• Obtained through questioning info that cannot be measured
• Data given by the PT or family includes the concerns/symptoms experienced by the PT
• Anything you cannot use your senses to confirm (touch, ear, see, or smell).
• Pain is subjective & is the 5th vital sign

Subjective data info

1. Chief complaint/problem - from the PT in their own words

2.The detailed HX of the present illness

3. PT's medical history (HX)

4. Family HX

5. Social Info - PT's job, education level, & cultural background

6. A review of problems found in different body systems

*info is subjective if you have to rely on the PT's words or cannot confirm, prove, or verify the issue/complaint with one of your senses

Objective Data

• Obtained through observation; information that is observed of could be verified by another

• PT's physical exams, documents brought in by the PT's (old lab results, electro cardio grams, EEG's, X-rays & med's brought in, vitals (respiratory, pulse, blood pressure, weight, height, & temperature)
• Things you can verify/confirm & use your senses to observe (see, feel, hear, & smell)

Objective Data Gathered through

the assessment physical findings

1. Inspection - close observation
2. Palpation - feeling
3. Percussion - feeling differences in vibrations through the skin
4. Ausculation - listening with the stethoscope
5. Results of recent lab test & diagnostic procedures

Five Step

Nursing Process

Broken Down

1. Assess

• HX
• Physical

2. Diagnose

• Primary medical problem
• Secondary medical problem
• Social, psychologic, educational, environmental, safety, nutritional problems

3. Plan

• Therapeutic goal
• Medication knowledge
• Special needs equipment
• Teaching needs

4. Implement

• Right drug
• Right time
• Right dose
• Right PT
• Right route
• Right documentation

5. Evaluate

• Therapeutic effects
• Adverse effects
• Allergy