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Nursing Process
Words to Know actual diagnosis assessment collaborative problems critical thinking data base assessment diagnosis evaluation focus assessment goal implementation long-term goals nursing diagnosis nursing orders nursing process objective data planning possible diagnosis potential diagnosis short-term goals signs standards for care subjective data symptoms syndrome diagnosis wellness diagnosis

Learning Objectives
On completion of this chapter, the reader will:
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Define nursing process. Describe six characteristics of the nursing process. List five steps in the nursing process. Identify four sources for assessment data. Differentiate between a data base assessment and a focus assessment. Distinguish between a nursing diagnosis and a collaborative problem. List three parts of a nursing diagnostic statement. Describe the rationale for setting priorities. Discuss appropriate circumstances for short-term and long-term goals. Identify four ways to document a plan of care. Describe the information that is documented in reference to the plan of care. Discuss three outcomes that result from evaluation.

n the distant past, nursing practice consisted of actions based mostly on common sense and the examples set by older, more experienced nurses. The actual care of clients tended to be limited to the physician’s medical orders. Although nurses today continue to work interdependently with physicians and other health care practitioners, they now plan and implement client care more independently. In even stronger terms, nurses are held responsible and accountable for providing client care that is appropriate and reflects currently accepted standards for nursing practice.

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problems of clients (Fig. 2-1). It is the accepted standard for clinical practice established by the American Nurses Association (ANA) (Box