9781422279885

information on the patient’s current health status but also his past medical history. Depending on the patient, other aspects of his life— including his psychological state, his religious affiliation, and his socioeconomic back- ground—may also be noted in the initial assessment. All this information is collected to help come up with a diagnosis and develop a treatment plan, which is the second aspect of the nursing process. 2. Diagnosis Following the assessment, a diagnosis is made. The patient’s health is fully reviewed by the nurse and the doctor, and together they come up with a diagnosis. The patient’s diagno- sis takes into account the amount of pain the patient is in, her background, her psychological status, and her current medica- tions. This diagnosis is the basis for the nurse’s care plan, which is the third step in the nursing process. 3. Goal Setting/Care Planning Based on the assessment and the diagnosis, the nurse sets measurable short- and long-term goals for the patient’s recov- ery and return to health. These goals may range from getting out of bed and walking down the hall, to passing a bowel move- ment post-surgery. Other common goals include managing Educational Video

For a brief overview of the nursing process, scan here.

12

Nurses