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Definition of Nursing Process
The nursing process is a critical thinking process that professional nurses uses to apply the best available evidence to care giving and promoting human functions and responses to health and illness
-American Nurses Association, 2010
It is the fundamental blue print for how to care for patients. The nursing process is also a standard of practice, which when followed correctly, protects nurses against legal problems related to nursing care.
The nursing process is goal-oriented method of caring that provides a framework to nursing care. It involves five major steps:
A - Assess (what data is collected?)
D - Diagnose (what is the problem?)
P - Plan (how to manage the problem)
I - Implement (putting plan into action) with Rationale (Scientific reason of the implementations)
E - Evaluate (did the plan work?)
According to some theorists, this seven-steps description of the nursing process is outdated and misrepresents nursing as linear and atomic.
The nurse completes an holistic nursing assessment of the needs of the individual/ family/community, regardless of the reason for the encounter. The nurse collects subjective data and objective data using a nursing framework, such as Marjory Gordon’s functional health patterns.
Nursing assessments provide the starting point for determining nursing diagnosis. It is vital that a recognized nursing assessment framework is used in practice to identify the patient’s problems, risks and outcomes for enhancing health. The use of an evidence-based nursing framework such as Gordon’s Functional Health Pattern Assessment should guide assessments that support nurses in determination of NANDA-I nursing diagnosis. For accurate determination of nursing diagnosis, useful, evidence-based assessment framework is best practice.
· Client Interview
· Physical Examination
· Obtaining a health history (including dietary data)
· Family history/report
Nursing diagnosis represent the nurse’s clinical judgment about actual or potential health problems/life process occurring with the individual, family, group or community. The accuracy of the nursing diagnosis is validated when a nurse is able to clearly identify and link to the defining characteristics, related factors and/or risk factors found within the patients assessment. Multiple nursing diagnosis may be made for one client.
In agreement with the client, the nurse addresses each of the problems identified in the diagnosing phase. When there are multiple nursing diagnosis to be addressed, the nurse prioritizes which diagnosis will receive the most attention first according to their severity and potential for causing more serious harm. For each problem a measurable goal/outcome is set. For each goal/outcome, the nurse selects nursing interventions that will help achieve the goal/outcome. A common method of formulating the expected outcomes is to use the evidence-based Nursing Outcomes Classification to allow for the use of standardized language which improves consistency of terminology, definition and outcome measures. The interventions used in the Nursing Interventions Classification again allow for the use of standardized language which improves consistency of terminology, definition and ability to identify nursing activities, which can also be linked to nursing workload and staffing indices. The result of this phase is a nursing care plan.
The nurse implements the nursing care plan performing the determined interventions that were selected to help meet the goals/ outcomes that were established. Delegated tasks and the monitoring of them is included here as well.
· pre-assessment of the client-done before just carrying out implementation to determine if it is relevant
· determine need for assistance
· implementation of nursing orders
· delegating and supervising-determines who to carry out what action
The nurse evaluates the progress toward the goals/outcomes identified in the previous phases. If progress towards the goal is slow, or if regression has occurred, the nurse must change the plan of care accordingly. Conversely, if the goal has been achieved then the care can cease. New problems may be identified at this stage, and thus the process will start all over again.
The nursing process is a cyclical and ongoing process that can end at any stage if the problem is solved. The nursing process exists for every problem that the individual/family/community has. The nursing process not only focuses on ways to improve physical needs, but also on social and emotional needs as well.
· Cyclic and dynamic
· Goal directed and client centred
· Interpersonal and collaborative
· Universally applicable
The entire process is recorded or documented in order to inform all members of the health care team.
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