Nursing process |
A deliberate problem-solving approach for meeting people’s health care and nursing needs; common components are assessment, diagnosis, planning, implementation, and evaluation |
Assessment |
The systematic collection of data to determine the patient’s health status and any actual or potential health problems |
Nursing diagnoses |
Actual or potential health problems that can be managed by independent nursing interventions |
Planning |
Development of goals and outcomes, as well as a plan of care designed to assist the patient in resolving the diagnosed problems and achieving the identified goals and desired outcomes |
Implementation |
Actualization or carrying out of the plan of care through nursing interventions |
Evaluation |
Determination of the patient’s responses to the nursing interventions and the extent to which the outcomes have been achieved. |
Nursing process implemented |
Hospitals that document all the components of nursing process in the patient file |