NCLEX Review Guide: Nursing Process & Documentation

Assessment (사정)

• Systematic collection of subjective and objective data about the client's health status through observation, interview, and physical examination.
• Primary data comes directly from the client, while secondary data comes from family, medical records, and other healthcare providers.

Nursing Diagnosis (간호진단)

• Clinical judgment about individual, family, or community responses to actual or potential health problems that nurses can independently treat.
• Uses NANDA-I approved diagnoses with three components: problem, etiology (related to), and signs/symptoms (as evidenced by).

Planning & Outcome Identification (계획 및 목표설정)

• Develops client-centered goals using SMART criteria (Specific, Measurable, Achievable, Realistic, Time-bound).
• Prioritizes nursing diagnoses using Maslow's hierarchy: physiological needs first, then safety, love/belonging, esteem, and self-actualization.

Implementation (수행)

• Carries out planned nursing interventions including independent, dependent, and collaborative actions.
• Documents all interventions immediately after completion to ensure accurate record-keeping and continuity of care.

Evaluation (평가)

• Determines whether client goals were met, partially met, or not met through ongoing assessment.
• Modifies the care plan based on evaluation findings to ensure optimal client outcomes.

Types of Nursing Interventions

• Independent interventions are actions nurses can perform without physician orders, such as patient education, positioning, and emotional support.
• Dependent interventions require physician orders, including medication administration and specific treatments.
• Collaborative interventions involve working with other healthcare team members to achieve client goals.

Outcome Identification Guidelines

1. Write outcomes in terms of client behavior, not nursing actions
2. Use measurable verbs (demonstrate, verbalize, maintain) rather than vague terms (understand, know)
3. Include specific criteria and timeframes for achievement
4. Ensure outcomes are realistic and achievable for the individual client

Legal and Ethical Aspects

• Documentation serves as legal evidence of care provided and must be accurate, complete, and timely.
• Follow the principle "if it wasn't documented, it wasn't done" - all nursing actions must be recorded.

Documentation Guidelines

• Use objective, factual language avoiding subjective interpretations or judgmental statements.
• Document in chronological order using approved abbreviations and correct spelling.
• Never leave blank spaces - draw a line through unused areas and initial.

Quick Check Questions

• ☐ Can I identify the correct sequence of the nursing process?
• ☐ Do I understand the difference between independent and dependent interventions?
• ☐ Can I write SMART goals for client outcomes?
• ☐ Do I know proper documentation guidelines?