The Nursing Process II

The two sources for collecting information are primary and secondary. After gathering information, interpretation and validation help to complete the …

Data collection gathers information needed to make accurate judgments about a patient's present condition. During a health history interview, …

The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The …

The physical assessment examines the patient for objective data that defines the patient's condition, and aids in formulating the nursing care plan. …

Data validation is an essential part of a comprehensive assessment. Validation is confirming or verifying and opening the door to gathering more …

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient …

Following assessment, a nursing diagnosis is the next step in the nursing process. It begins after the nurse has collected and recorded the patient data. …

A nursing diagnosis is written when the nurse recognizes a cluster of essential patient data indicating health problems treated with independent nursing …

Nursing diagnoses represent a problem validated by major defining characteristics. There are four categories of nursing diagnoses: problem-focused, risk, …

The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a …