Assessment and Diagnosis Components of the Nursing Process
Aldecia Blackwood
ITT Technical Institute
ASSESSMENT AND DIAGNOSIS COMPONENTS
Abstract
The nursing process is an organized critical thinking system used by professional nurses to give the best optimal care to clients. “It is very similar to the steps used in scientific reasoning and problem solving.” (Ackley and Ladwig, 2014:2). It contains five steps; Assessment, Diagnosis, plan, implementation of care, and evaluation. Assessment is collected first by doing a health and medical history, and by listening to and observing the client. To obtain as much information as possible to start the process, several open-ended questions are asked. Data is also obtained from physiological factors; taking vitals, and doing diagnostic test. “In the nursing diagnosis phase of the nursing process, the nurse begins clustering the information within the client story and formulates an evaluative judgment about a client’s health status.” (Ackley and Ladwig, 2014:3). Assessment and diagnosis are the first two main important steps of the nursing process where the foundations of all care plans are developed.
ASSESSMENT AND DIAGNOSIS COMPONENTS
Assessment and Diagnosis Components of the Nursing Process Nursing process is an organized system that is used in the practice of nursing. It involves all the steps taken by a nurse when performing care for a patient: Assessment, nursing diagnosis, planning, implementation, and evaluation. This process uses a systemic process to each individual situation, commencing with assessment, including evaluation and a reconciliation of the patient, their family members and the nurse. “It is very similar to the steps used in scientific reasoning and problem solving” (Ackley and Ladwig) . Each step follows each other at the beginning of the process but may need to be concurrent in different situations. In this paper