The first step of the nursing process is assessing the patient. During this phase, the nurse will consider the patient's overall health status. The nurse can interview the patient, refer to the patient's health and family history, and do a physical examination. A major portion of this phase is to interact with the patient in order to evaluate their health.
The second phase of the nursing process is diagnosing. During this phrase, the nurse makes an educated judgment about a potential or actual health problem with a patient. The patient may have mulitple diagnoses. As a nurse, you have to think to a deeper extent to whether or not the patient is at risk of developing additional problems. Once the patient has been diagnosed, you can start to plan a health readiness component to treat or safely discharge the patient from the hospital setting. …show more content…
When brainstorming about the care, use the assessment and diagnosis to create measureable and achieveable short and long term goals for the patients. Once the diagnoses has been determined, the nurse can create a care plan for the patient. If there are multiple diagnoses, it is important to prioritize each assessment from the most important diagnoses to a least greater harm of diagnoses. Each diagnoses has a measurable goal for the patient to reach whether is it by the end of the nurse's shift, the end of discharge or a long-term goal after discharge. When implementing the diagnoses, the time frame can vary from hours to days to weeks or even months. While thinking about the interventions, it is inportant to use evidence-based Nursing Outcome to track the patient's