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The Nursing Process
The Nursing Process
• An organizational framework for the practice
of nursing
• Orderly, systematic
• Central to all nursing care
• Encompasses all steps taken by the nurse in
caring for a patient
The Nursing Process
• Assessment
• Nursing Diagnosis
• Planning
• Implementation
• Evaluation
The Nursing Process
Assessment
• Data collection
(subjective, objective, environmental)
• Medication history
• Nursing assessment
• Data analysis
The Nursing Process
Nursing Diagnosis
• Judgment or conclusion about the risk for—or
actual—need/problem of the patient
• NANDA format
The Nursing Process
Planning
• Identification of goals and outcome criteria
• Prioritization
• Time frame
The Nursing Process
Implementation
• Initiation and completion of the nursing care plan
as defined by the nursing diagnoses and outcome
criteria
• Follow the “five rights” of medication administration
The “Five Rights” of
Medication Administration
• Right drug
• Right dose
• Right time
• Right route
• Right patient
The “Sixth Right”—System Analysis
• The entire “system” of medication
administration:
• Ordering, dispensing, preparing,
administering, documenting
The Nursing Process
Evaluation
• Ongoing part of the nursing process
• Determining the status of the goals and
outcomes of care
• Monitoring the patient’s response to drug therapy