Nursing process

As far as I know, all US Nursing schools are teaching the nursing process and using care planning (or concept mapping) and nursing diagnosis to choose appropriate interventions for patients.

My hospital uses a standardized care planning form that includes things that need to be assessed on every patient, with appropriate interventions for things like skin care, pain, and education. The nurse writes the remainder of the care plan with nursing diagnoses and interventions appropriate to that patients' condition. For example, I work in SICU and we include 'risk for' or true hemodynamic status and oxygenation nursing diagnoses on every patient.

Hope that helps.

In school, we used the NANDA nursing diagnosis labels when planning care for our assigned patients.

After I graduated, I never used the nursing diagnosis label again. But it was a helpful learning tool for discerning the difference between strictly medical interventions and those we can do for our patients that do not require a doctor's orders.

Our admitted patients have a "care plan" document (it is a form with checkboxes) that is mulitdisciplinary in nature. Nursing, Respiratory Therapy, Social Work, Physical and Occupational Therapy all use it as a way to document that goals for discharge have all been met. Sad thing is, I doubt that the docs look at it when they are in the chart. So the actual discharge of the patient really doesn't have much to do with whether or not teaching or therapies have been effective or ineffective.

Blee