🩺 NURSING PROCESS

The Nursing Process is a systematic, scientific, and dynamic method used by nurses to plan and provide individualized patient care. It helps in identifying patient needs, organizing nursing actions, and evaluating outcomes to ensure quality nursing care.

It is the foundation of professional nursing practice and ensures logical, evidence-based, and goal-directed care.

🧠 1️⃣ Assessment

👉 Meaning:
It is the first and most critical step where the nurse collects complete, accurate, and relevant information about the patient’s health status.

🩹 Purpose:
To establish a database about the patient’s physical, psychological, social, and spiritual condition.

📋 Types of Data:

• Subjective Data – What the patient says (e.g., pain, nausea, anxiety).
• Objective Data – What the nurse observes or measures (e.g., vital signs, lab reports, physical examination findings).

🔍 Sources of Data:

• Patient
• Family and caregivers
• Health records
• Diagnostic reports
• Health team members

💡 Example:
Patient reports “I have chest pain” (subjective) and ECG shows abnormal results (objective).

⁕GIVING NURSING ASSESMENT IN DETAIL:-

🩺 NURSING ASSESSMENT

🌼 Meaning:

Nursing Assessment is the first and most crucial step of the nursing process. It involves systematic and continuous collection, organization, validation, and documentation of patient data to determine the person’s health status, needs, and responses to actual or potential health problems.

👉 It provides the foundation for planning and implementing nursing care.

🌟 Purpose of Nursing Assessment:

1. 🧠 To identify actual or potential health problems.
2. 🫀 To collect baseline data about the patient’s physical, psychological, social, and spiritual health.
3. ✍️ To establish priorities of care.
4. 🤝 To build a therapeutic relationship between nurse and patient.
5. 📊 To provide data for nursing diagnosis and care planning.

🧩 Types of Nursing Assessment:

1. 🕐 Initial Assessment:
   • Done on admission or first contact with the patient.
   • Provides baseline information for future comparison.
2. 🔄 Ongoing Assessment:
   • Performed continuously during care to identify changes in condition.
3. ⚕️ Focused Assessment:
   • Concentrates on a specific problem or body system.
   • Example: Respiratory assessment for a patient with dyspnea.
4. 🚨 Emergency Assessment:
   • Done rapidly in life-threatening situations (e.g., airway obstruction, cardiac arrest).

🧠 Steps of Nursing Assessment:

1️⃣ Data Collection 🗂️

Gather information about the patient’s health through:

• Subjective data (Symptoms):
  Information the patient tells the nurse (e.g., “I feel pain in my chest”).
• Objective data (Signs):
  Information observed or measured by the nurse (e.g., pulse rate 90 bpm, BP 130/80 mmHg).

Methods of Data Collection:

• 👂 Interview (history taking)
• 👁️ Observation
• ✋ Physical Examination
• 📄 Review of records/reports

2️⃣ Data Organization 📚

Collected data is classified under categories such as:

• Physical
• Emotional
• Social
• Cultural
• Spiritual

This helps to form a complete picture of the patient’s health.

3️⃣ Data Validation ✅

• Ensures accuracy and completeness of collected data.
• Nurse verifies doubtful or inconsistent findings through cross-checking with patient, family, or medical records.

4️⃣ Data Documentation 🖋️

• All findings are recorded immediately in the patient’s health record.
• Documentation should be:
  • Accurate
  • Objective
  • Clear
  • Legally valid

🩶 Example:

“Patient reported nausea since morning; pulse 88 bpm; skin warm and dry.”

💉 Components of Nursing Assessment:

1. 🧍‍♀️ Physical Assessment:
   • Vital signs (Temperature, Pulse, Respiration, BP)
   • Head-to-toe examination (inspection, palpation, percussion, auscultation)
2. 🧘‍♀️ Psychological Assessment:
   • Emotional state, mood, behavior, stress levels.
3. 👨‍👩‍👧 Social Assessment:
   • Family relationships, occupation, lifestyle, social support.
4. 🙏 Spiritual Assessment:
   • Beliefs, values, and practices influencing health.
5. 🍲 Nutritional Assessment:
   • Diet habits, appetite, BMI, nutritional deficiencies.
6. 🧾 Environmental Assessment:
   • Living conditions, hygiene, sanitation, safety.

💬 Characteristics of Effective Assessment:

✨ Accurate
✨ Systematic
✨ Continuous
✨ Holistic
✨ Documented
✨ Client-centered

💎 Nurse’s Role in Assessment:

• 🩺 Establish rapport and trust.
• 📋 Collect complete and relevant data.
• 🧩 Interpret findings logically.
• 🔍 Identify deviations from normal.
• 💬 Communicate findings to healthcare team
• .🌿 ASSESSMENT OF BODY AND ABDOMEN IN NURSING
  🌸 Meaning:
  Abdominal and general body assessment is a systematic physical examination performed by the nurse to observe, palpate, percuss, and auscultate various areas of the body — particularly the abdomen — to detect normal functions and early signs of disease.
  It helps to evaluate the digestive system, urinary system, and other abdominal organs like the liver, stomach, spleen, pancreas, kidneys, and intestines.
  
  🌟 GENERAL STEPS OF BODY ASSESSMENT
  Before focusing on the abdomen, every complete physical assessment follows four core techniques in a specific order:
  1️⃣ Inspection 👀
  2️⃣ Palpation ✋
  3️⃣ Percussion 👂
  4️⃣ Auscultation 🎧
  👉 However, in abdominal examination, the order changes slightly:
  Inspection → Auscultation → Percussion → Palpation
  (because palpation or percussion before auscultation may alter bowel sounds).
  
  🧍‍♀️ PREPARATION BEFORE ABDOMINAL ASSESSMENT
  ✨ Environment: Quiet, private, and well-lit room.
  ✨ Position: Patient in supine (lying flat) position with knees slightly flexed to relax the abdominal muscles.
  ✨ Expose only the abdomen and cover other parts for privacy.
  ✨ Warm hands and stethoscope to avoid muscle tension.
  ✨ Ask patient to empty the bladder before examination.
  
  🩻 STEP 1: INSPECTION 👁️
  Definition:
  Careful visual observation of the abdomen for size, shape, color, movement, and any abnormalities.
  Procedure:
  Stand on the patient’s right side.
  Observe the skin color (pale, jaundiced, cyanotic).
  Note shape:
  Flat – normal
  Rounded/obese – may be due to fat
  Scaphoid (sunken) – malnutrition
  Distended – gas, fluid, or mass
  Look for symmetry of both sides.
  Observe for visible peristalsis or pulsations.
  Check for scars, striae (stretch marks), rashes, or dilated veins.
  Watch for movement during respiration (abdomen should rise smoothly).
  Abnormal Findings:
  Hernia (bulging area)
  Visible veins (portal hypertension)
  Asymmetry (tumor, enlarged organ)
  
  🎧 STEP 2: AUSCULTATION 👂
  Definition:
  Listening to internal sounds of the abdomen using a stethoscope.
  Purpose:
  To assess bowel sounds and vascular sounds.
  Procedure:
  Place the diaphragm of the stethoscope lightly on the skin.
  Start in the right lower quadrant (RLQ) and proceed clockwise (RLQ → RUQ → LUQ → LLQ).
  Listen for frequency and character of bowel sounds:
  Normal: Irregular gurgles every 5–30 seconds.
  Hyperactive: “Borborigmus” — frequent, loud gurgling sounds (diarrhea, early obstruction).
  Hypoactive/Absent: May indicate ileus or peritonitis (listen for 5 full minutes before confirming absence).
  Also listen for:
  Bruits over the aorta, renal, or femoral arteries (suggests narrowing or aneurysm).
  
  🥁 STEP 3: PERCUSSION 🩻
  Definition:
  Tapping the body surface to assess density, size, and position of underlying organs or presence of fluid/gas.
  Procedure:
  Percuss in all four quadrants of the abdomen.
  Note the sound produced:
  Tympany → over stomach and intestines (air-filled).
  Dullness → over liver, spleen, or a full bladder (solid or fluid).
  Flatness → over bones.
  Special tests:
  Liver Span Percussion: Measure vertical height of dullness at midclavicular line (~6–12 cm).
  Splenic Dullness: Check in the left upper quadrant.
  Shifting Dullness/Fluid Wave Test: Used to detect ascites (free fluid) in peritoneal cavity.
  
  ✋ STEP 4: PALPATION 🖐️
  Definition:
  Using the hands to feel structures beneath the surface for tenderness, masses, or organ enlargement.
  Technique:
  Always start with light palpation (1–2 cm deep) to detect tenderness or superficial masses.
  Proceed to deep palpation (4–5 cm deep) to feel deeper organs.
  Ask the patient to breathe slowly and relax muscles.
  What to feel for:
  Texture and consistency of tissues
  Muscle tone and tenderness
  Enlargement of liver or spleen
  Presence of lumps, rigidity, or rebound tenderness
  Palpate specific organs:
  Liver: Right upper quadrant; normally not palpable, but edge may be felt on deep inspiration.
  Spleen: Left upper quadrant; enlarged in malaria, leukemia, etc.
  Kidneys: Use bimanual technique (from front and back).
  Bladder: Palpable when full above pubic symphysis.
  Abnormal Findings:
  Guarding or rigidity → peritonitis
  Tenderness → appendicitis, cholecystitis
  Mass → tumor, cyst, enlarged organ
  
  🌈 ADDITIONAL OBSERVATIONS IN ABDOMINAL ASSESSMENT
  Umbilicus: Check for position, hernia, or discharge.
  Bowel Movements: Ask about frequency, color, and consistency.
  Urination pattern: For urinary system involvement.
  Pain Assessment: Note site, nature, radiation, aggravating/relieving factors.

💭 2️⃣ Nursing Diagnosis

👉 Meaning:
It is a clinical judgment made by the nurse about the patient’s response to actual or potential health problems.

🩺 Purpose:
To identify nursing problems that can be prevented or treated through nursing interventions.

⁕GIVING NURSING DIAGNOSIS IN DETAIL:-

🩷 Meaning of Nursing Diagnosis

A Nursing Diagnosis is a clinical judgment made by the nurse about a patient’s response to actual or potential health problems or life processes.
It provides the basis for nursing interventions that aim to achieve outcomes for which the nurse is accountable.

👉 It focuses on the patient’s response, not the disease itself.
👉 It is a core component of the Nursing Process (Assessment → Diagnosis → Planning → Implementation → Evaluation).

🧠 Definition (NANDA-I)

According to NANDA International (NANDA-I):

“A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.”

🌈 Purpose of Nursing Diagnosis

✨ Helps identify actual or potential problems.
✨ Provides a scientific basis for nursing actions.
✨ Promotes effective communication among healthcare professionals.
✨ Guides planning of individualized care.
✨ Enhances evaluation of nursing outcomes.

🧩 Types of Nursing Diagnoses

1. 💉 Actual Nursing Diagnosis:
   • Represents a current problem that is validated by signs and symptoms.
   • Example: Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by shortness of breath and low oxygen saturation.
2. ⚠️ Risk Nursing Diagnosis:
   • Describes a problem that may develop in the future if preventive measures are not taken.
   • Example: Risk for Infection related to surgical incision.
3. 🌱 Health Promotion Diagnosis:
   • Reflects a patient’s readiness to enhance health or wellness.
   • Example: Readiness for Enhanced Nutrition as expressed by desire to learn about balanced diet.
4. 🌙 Syndrome Diagnosis:
   • A cluster of problems that occur together and require similar interventions.
   • Example: Post-Trauma Syndrome or Disuse Syndrome.
5. 🧬 Possible Nursing Diagnosis:
   • A problem that may be present but needs more data for confirmation.
   • Example: Possible Chronic Low Self-Esteem related to unemployment.

💡 Components of a Nursing Diagnosis (PES Format)

Each diagnosis has three parts (when applicable):

1. P – Problem: The diagnostic label (what is wrong).
2. E – Etiology: The cause or contributing factor (“related to…”).
3. S – Symptoms: The defining characteristics (“as evidenced by…”).

👉 Example:
Impaired Physical Mobility related to weakness and pain as evidenced by difficulty walking and decreased muscle strength.

🧾 Examples of NANDA-Approved Nursing Diagnoses

🩸 1. Acute Pain – related to physical injury agent as evidenced by verbal expression of pain.
🫁 2. Impaired Gas Exchange – related to alveolar membrane changes as evidenced by dyspnea and hypoxia.
🧍‍♀️ 3. Impaired Skin Integrity – related to pressure over bony prominence as evidenced by stage-2 pressure ulcer.
🌡️ 4. Hyperthermia – related to infection as evidenced by increased body temperature.
🧠 5. Anxiety – related to situational crisis as evidenced by restlessness and verbal expressions of concern.
💤 6. Disturbed Sleep Pattern – related to environmental noise as evidenced by complaints of sleeplessness.
💧 7. Deficient Fluid Volume – related to excessive fluid loss as evidenced by dry mucous membranes and decreased urine output.
🍎 8. Imbalanced Nutrition: Less than Body Requirements – related to poor appetite as evidenced by weight loss.
🏥 9. Risk for Falls – related to altered mobility and use of sedative medication.
💓 10. Ineffective Coping – related to prolonged stress as evidenced by inability to meet role expectations.

🌺 Steps in Formulating a Nursing Diagnosis

1. 🩺 Collect Data – From physical, emotional, and social assessment.
2. 🧠 Analyze Data – Identify abnormal patterns and deviations.
3. 🧩 Identify Problem – Focus on patient’s response to the condition.
4. 🪶 Formulate Statement – Using “Problem related to cause as evidenced by signs/symptoms.”
5. ✍️ Validate Diagnosis – Confirm with patient and review clinical accuracy.

🔍 Example of Complete Nursing Diagnosis Process

Assessment Data:
Patient reports difficulty breathing, O₂ saturation 88%, respiratory rate 28/min.

Diagnosis:
👉 Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by dyspnea and low oxygen saturation.

Nursing Goal:
To maintain optimal oxygen saturation above 95%.

Interventions:

• Administer oxygen as prescribed.
• Encourage deep breathing and positioning.
• Monitor respiratory rate and O₂ saturation.

Evaluation:
Goal achieved – O₂ saturation improved to 96%.

🎯 3️⃣ Planning

👉 Meaning:
After identifying nursing diagnoses, the nurse develops a care plan that sets priorities, goals, and expected outcomes.

📝 Purpose:
To design a course of action that directs nursing activities toward achieving measurable results.

🌟 Meaning / Definition

Nursing Planning is the second step of the nursing process (after assessment and diagnosis).
It involves setting priorities, establishing patient-centered goals, and deciding nursing interventions that will help to solve or prevent the patient’s health problems.

🧠 In short:

“It is a systematic process of designing a plan of care to achieve desired outcomes for the patient.”

🎯 Purpose / Objectives

1. 🩹 To provide individualized and goal-directed care.
2. 🧾 To ensure continuity of care among different nurses or shifts.
3. 💡 To help in effective utilization of time and resources.
4. 🧍‍♀️ To promote active participation of patient and family.
5. 📈 To serve as a guide for evaluation of nursing care outcomes.

🧩 Types of Planning

1. 🕒 Initial Planning:
   • Done immediately after assessment.
   • Developed by the nurse who performs the initial history and examination.
   • Example: A nurse plans IV fluid therapy for a dehydrated patient on admission.
2. 🔁 Ongoing Planning:
   • Done throughout the hospital stay.
   • Allows modification as per patient’s progress or new data.
   • Example: Plan modified to reduce IV rate once oral fluids are tolerated.
3. 🏠 Discharge Planning:
   • Begins from the time of admission and focuses on continuity of care after discharge.
   • Example: Teaching a diabetic patient how to self-administer insulin before going home.

📍 Steps in Nursing Planning

1. Prioritize Problems:
   • Identify which problems are urgent (life-threatening) and which are secondary.
   • Example: In a burn patient, airway maintenance is a higher priority than skin care.
2. Set Goals and Expected Outcomes:
   • Goals must be SMART:
     • Specific
     • Measurable
     • Achievable
     • Realistic
     • Time-bound
   • Example: “Patient will maintain temperature within normal range within 24 hours.”
3. Select Nursing Interventions:
   • Choose independent, dependent, and collaborative interventions.
   • Example: Administer antipyretic as prescribed, encourage fluid intake, and monitor temperature.
4. Write Nursing Care Plan:
   • A formal document containing:
     • Problem/diagnosis
     • Goal/objective
     • Nursing interventions
     • Rationales
     • Evaluation criteria

🧍‍♀️ Characteristics of a Good Nursing Plan

• 💬 Patient-centered – focuses on individual needs.
• ⏱ Realistic and achievable – based on available resources.
• 📚 Evidence-based – guided by current nursing research.
• 🔁 Flexible – can be modified according to patient response.
• 🩺 Holistic – includes physical, psychological, social, and spiritual aspects.

💉 Example:

Nursing Diagnosis:
Impaired physical mobility related to weakness secondary to fracture.

Goal:
Patient will regain mobility of affected limb within 2 weeks.

Interventions:

• Encourage active and passive exercises.
• Assist with walking using walker.
• Provide emotional support and motivation.
• Educate patient about physiotherapy.

Expected Outcome:
Patient performs daily activities independently within 2 weeks.

📘 Importance of Nursing Planning

1. 🧾 Provides a written guideline for all healthcare team members.
2. 🧠 Improves critical thinking and clinical decision-making skills.
3. 🤝 Ensures team coordination and communication.
4. 🔄 Facilitates evaluation by comparing actual and expected outcomes.

💉 4️⃣ Implementation

👉 Meaning:
This step involves putting the care plan into action — performing nursing interventions to meet patient goals.

🩹 Purpose:
To carry out planned actions safely and effectively to improve or maintain patient health.🌼 Meaning of Nursing Implementation

👉 Nursing Implementation is the fourth step of the Nursing Process (after assessment, diagnosis, and planning).
It refers to putting the nursing care plan into action — that means performing the nursing interventions to achieve the desired patient outcomes.
In simple words:

“Doing what we planned to help the patient.” 💪

🌟 Definition

Implementation is the process of initiating, performing, and documenting specific nursing actions that are necessary to accomplish the goals and expected outcomes identified in the care plan. 📝

💡 Objectives of Nursing Implementation

✨ To provide safe, effective, and evidence-based care.
✨ To help the patient achieve optimal health and recovery.
✨ To ensure continuity of care among the healthcare team.
✨ To promote patient participation and education.

🔶 Steps in Nursing Implementation

Each step should be carried out systematically to maintain quality of care.

1️⃣ Reassess the Client

Before performing any action, reassess the patient’s condition.
🩺 Example: Before giving insulin, check the patient’s blood glucose again.

2️⃣ Review and Modify the Care Plan if Needed

Sometimes, the patient’s condition changes.
If something new occurs, the nurse must update the plan accordingly.
🩷 Example: If a patient develops a fever, add temperature monitoring and antipyretic administration to the plan.

3️⃣ Organize and Prepare for Implementation

The nurse arranges resources, equipment, and ensures safety measures.
⚙️ Example: Preparing sterile equipment before doing wound dressing.

4️⃣ Perform Nursing Interventions

This is the action phase — carrying out direct or indirect care activities.
🫶 Example:

• Direct care → Administering medication 💉
• Indirect care → Communicating with the doctor or updating records 🗂️

5️⃣ Document the Care Provided

📋 Documentation is a legal and professional responsibility.
It should include what was done, when, how, and patient’s response.
🧾 Example: “At 8:00 AM, IV antibiotic administered as per order. Patient tolerated well.”

🌿 Types of Nursing Interventions

🔹 Independent Nursing Actions

Performed by nurse without physician’s order.
🩹 Example: Positioning patient for comfort, health teaching, emotional support.

🔹 Dependent Nursing Actions

Require physician’s order.
💊 Example: Administering prescribed medication, oxygen therapy.

🔹 Collaborative (Interdependent) Actions

Performed in collaboration with other healthcare members.
👩‍⚕️ Example: Working with physiotherapist for rehabilitation exercises.

⚙️ Types of Nursing Interventions:

• Independent: Performed by the nurse (e.g., repositioning, health teaching).
• Dependent: Requires doctor’s order (e.g., administering prescribed medication).
• Collaborative: Carried out with other health professionals (e.g., physiotherapy coordination).

💡 Example:
Administering analgesics as prescribed and encouraging deep breathing exercises.

📊 5️⃣ Evaluation

👉 Meaning:
This is the final step where the nurse determines whether the goals and outcomes were achieved.

🔎 Purpose:
To check the effectiveness of nursing care and decide if the plan needs to be continued, modified, or terminated.

🧩 Steps in Evaluation:

• Compare actual patient response with expected outcomes.
• Analyze causes of any unmet goals.
• Revise the care plan if necessary.

✅ Example:
If the patient reports pain relief from 8/10 to 2/10, the intervention is effective.

🌟 Characteristics of the Nursing Process

💠 Systematic: Follows a logical order.
💠 Dynamic: Steps are flexible and may overlap.
💠 Goal-oriented: Focuses on achieving patient-centered outcomes.
💠 Cyclic: Begins again as new problems arise.
💠 Universal: Applicable in all health care settings.

⁕ GIVING NURSING EVALUATION IN DETAIL

🌟 NURSING EVALUATION

🩺 Meaning / Definition

Nursing Evaluation is the final step of the nursing process 🧠.
It involves measuring the degree to which the patient’s goals and expected outcomes are achieved after the nursing interventions are implemented.
It helps the nurse to decide whether to continue, modify, or terminate the plan of care.

👉 In simple words:
It’s a systematic review of the patient’s progress toward achieving the planned outcomes.

🎯 Purpose / Objectives

✅ To determine the effectiveness of nursing interventions.
✅ To identify progress or lack of progress toward health goals.
✅ To ensure quality of patient care and patient safety.
✅ To decide whether care plan needs revision.
✅ To provide a basis for documentation and future planning.

🔍 Characteristics of Evaluation

• Continuous Process: Evaluation occurs throughout patient care, not just at the end.
• Goal-Oriented: Focused on whether goals/outcomes have been achieved.
• Patient-Centered: Based on patient’s responses and needs.
• Objective and Measurable: Uses observable data and clinical evidence.
• Dynamic: Adjusts as patient’s condition changes.

🧩 Steps of Nursing Evaluation

1. Collect Data Related to Outcomes 🧾
   • Gather subjective (patient says) and objective (what nurse observes) data.
   • Example: If goal was “pain will be reduced,” check pain score, facial expressions, vital signs.
2. Compare Data with Expected Outcomes ⚖️
   • Assess if patient’s response meets the goal.
   • Example:
     • Goal: Pain score ≤ 3 within 2 hours.
     • Result: Pain score is 2 → Goal achieved.
     • Result: Pain score is 6 → Goal not achieved.
3. Relate Nursing Actions to Outcomes 🔗
   • Decide whether the nursing interventions directly influenced the outcomes.
   • Example: After giving analgesic and providing comfort, pain reduced → interventions effective.
4. Draw Conclusions About Problem Status 🩹
   • Three possible conclusions:
     • Goal achieved ✅
     • Goal partially achieved ⚠️
     • Goal not achieved ❌
5. Modify, Continue, or Terminate Care Plan 🔄
   • If achieved → Terminate that part of plan.
   • If partially achieved → Continue or revise interventions.
   • If not achieved → Reassess and create new strategies.

🧠 Types of Evaluation

1. Ongoing Evaluation 🔁
   • Done during care to monitor progress.
   • Example: Checking wound healing daily.
2. Intermittent Evaluation ⏱️
   • Done at specific intervals to assess changes.
   • Example: Assessing blood pressure improvement every week.
3. Terminal Evaluation 🏁
   • Done at discharge or completion of care.
   • Example: Evaluating recovery status of post-operative patient before discharge.

🧾 Documentation in Evaluation

🖊️ Every finding must be recorded in the patient’s chart.
Include:

• Date, time, data collected
• Outcome status (achieved/partially achieved/not achieved)
• Modifications made
• Signature of nurse

Example:

“10/17/25, 10:00 AM – Pain score reduced from 8 to 2 within 1 hour after analgesic and relaxation therapy. Goal achieved. Plan terminated.” 👏

🧑‍⚕️ Example in Clinical Context

Scenario:
A patient with hypertension had a nursing goal –

“Patient’s blood pressure will remain below 130/80 mmHg within 3 days.”

Evaluation:
After 3 days of medication, diet education, and relaxation therapy –
BP measured: 128/78 mmHg ✅ → Goal achieved
Nurse documents result and discontinues that care plan.

💡 Importance of Nursing Evaluation

🌼 It ensures accountability in nursing care.
🌼 Promotes evidence-based practice.
🌼 Encourages critical thinking and professional growth.
🌼 Enhances patient satisfaction and continuity of care.