The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care.Īssessment Īnalysis or diagnosis The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using an age or condition appropriate pain scale. Subjective and objective data collection are an integral part of this process. It is the first step in the successful evaluation of a patient. The nursing assessment includes gathering information concerning the patient's individual physiological, psychological, sociological, and spiritual needs. This concept of precision education to tailor care based on an individual's unique cultural, spiritual, and physical needs, rather than a trial by error, one size fits all approach results in a more favorable outcome. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts. The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data sorting, analyzing, and organizing that data and the documentation and communication of the data collected.
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