# Chapter 4 The Nursing Process and Decision Making

What is the difference between the role of the RN and the role of the LPN/LVN in the nursing process?
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Terms in this set (58)
• Assessment is the gathering of information through signs and symptoms, patient history, and objective findings. Just as a physician gathers information by performing a physical examination and a patient history, the nurse gathers information
performing a head-to-toe assessment, and reviewing
laboratory and diagnostic tests.
• Diagnosis is the formulation of nursing diagnoses through analysis of the assessment information that you have gathered. The nursing diagnoses are related to the needs or problems the patient is experiencing. These are completely
different than medical diagnoses and are selected based on
definitions and defining characteristics.
• Planning is the process of determining priorities and what
nursing actions should be performed to help resolve or
manage each patient problem. In addition, the nurse determines
expected outcomes for the patient to meet for
the nursing diagnosis to be resolved, as well as a realistic
time frame for that to occur. The nurse then decides on
appropriate interventions to resolve each patient problem
or nursing diagnosis.
• Implementation is the process of taking actions to resolve
the patient's problems, the nursing diagnoses. These actions
are also called interventions. When the nurse performs
these interventions, it is called implementation. The nurse
implements the plan to help resolve the patient's problems.
• Evaluation is performed when the nurse reflects on the interventions
he or she has performed and decides if they
have brought the patient closer to achieving the goals and
outcomes set in the planning step. If not, the nurse then revises
and changes the interventions and
Interviewing, which involves asking questions, listening,
and using both verbal and nonverbal communication skills. Performing a focused body system assessment to determine deviations from normal in the patient's physical condition. Reviewing the results of laboratory and diagnostic tests to determine problems and needs caused by abnormal findings.
Write a three-part nursing diagnosis for a patient with constipation. If a patient was complaining of constipation, the nurse would assess the date of the last bowel movement and assess the abdomen.
The nurse would use independent interventions to help promote peristalsis, such as increasing fluid intake, encouraging high-fiber foods, and assisting with ambulation if allowed. The nurse also would administer laxatives or stool softeners as ordered by the physician. If the patient still was unable to
have a bowel movement and further orders were needed, the nurse would call the physician to obtain an order to administer an enema to the patient. Nurses always need an order from a health-care provider for diet, activity level, medications, IV therapy, treatments, diagnostic tests, and discharge
Student care plans have been used to help students make connections between the patient's medical diagnoses, medications, laboratory and diagnostic
tests, assessment data, nursing diagnoses, nursing orders or interventions, and evaluations. They also help sharpen Critical thinking and nursing decision making skills.