Nursing Process
Team C
Holly Briner
Lee Castro
Stephanie Collins
Brandon Hazlett
Tammy Moore
Jennifer Smith
Assessment
Nur/403
Ms. Van Baren
07/14/2014
Diagnosis
Plan
Implementati
on
Evaluation
Nursing Process
Assessment
Assessment is the first step in the Nursing Process. This helps to determine the Nursing Diagnosis and Plan of care that nurses will need for their patient. All of the information collected in each step will help determine and design the plan of care. Finding out what the patients psychological, sociocultural, spiritual and environmental beliefs can be the perfect start. (Ackley & Ludwig, 2010). Next nurses need to find out statistics such as blood pressure, temperature, breath sounds and more. This will help determine another piece of …show more content…
Obtaining the health and medical history is essential. It is important to know if the patient has other medical problems to assist in finding the most proper nursing diagnosis. When asking questions such as “what made you come in tonight?,” “What have you tried for this issue so far?,” “What would you like to see happen with today’s visit?”
The answers do help us put another piece of the puzzle together. Doing a complete physical exam can be one of the last pieces of this puzzle for the Assessment phase. It is important to do vitals, look over all diagnostic test results, do a head to toe physical exam as well as looking into the persons mental health well being. An example would be if a patient has
COPD and anxiety problems, what can we do in our nursing process to help address both issues to improve the patients outcome? Doing the Assessment phase will determine what the next step should be.
Physica l Assess ment First step in the process
of