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The nursing process is a modified scientific method which is a fundamental part of nursing practices in many countries around the world. [ 1 ] [ 2 ] [ 3 ] Nursing practise was first described as a four-stage nursing process by Ida Jean Orlando in 1958. [ 4 ]
The CCC is a nursing terminology specifically developed for computerization: e.g. electronic healthcare information systems (EHR), computer-based patient records (CPR), and Clinical Information Systems (CIS), from research which collected live patient care data. The CCC System describes the six steps of the nursing process: Assessment; Diagnosis
Roy employs a six-step nursing process: assessment of behaviour; assessment of stimuli; nursing diagnosis; goal setting; intervention and evaluation. In the first step, the person's behaviour in each of the four modes is observed. This behaviour is compared with norms and is deemed either adaptive or ineffective.
In general terms, the nursing process is the method used to assess and diagnose needs, plan outcomes and interventions, implement interventions, and evaluate outcomes. The nursing process as defined by the American Nurses Association comprises five steps: 1) evaluate, 2) implement, 3) plan, 4) diagnose, and 5) assess. [60]
The Iowa Model is used to promote quality of care. It is a guideline for nurses in their decision-making process. The decision making can include clinical and administration practices. These practices affect patient outcomes. The model is based on problem-solving steps that are a part of the scientific process.
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...
A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.
Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.