Nursing process refers to the system of assessment, evaluation, and planning which goals are to deliver personalized patient care irrespective of whether it is done to a single person, family, or an entire community. It aims at identifying existing gaps in the provision of health services for clients in order to overcome health issues. When the information has been collected and evaluated, a decision is then arrived depending on the need of a given situation. The nursing process is composed of five steps, namely assessment, diagnosis, planning, implementing, and evaluating. This report looks into the meaning and the usage of the nursing process towards formulating effective nursing conclusions, development of care plans by using different processes for a specific situation and offers a preparation strategy for creating an important teaching plan in preventing recurrence of similar situations.
Part 1: The Meaning and the Use of the Nursing Process
This is the first phase in the nursing procedure which involves “collection of data, verification, organization as well as interpretation and documentation of the collected data”. The accuracy and completeness of the information taken during this process are directly connected with the correctness of the following steps.
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Data is obtained from different sources; however, the client should be considered as the basic source of it. Other information providers like family members and friends are considered as secondary sources. Assessment stage offers significant information that forms the client database. There are two types of information collected: subjective and objective information. Subjective information indicates the client’s point of view and includes feelings, concerns, and perceptions. On the other hand, objective information details the observable as well as measurable data which are obtained through standard assessment methods during the client’s physical examination. A good example of it would be body temperature. Validation is a significant step in this assessment stage because it ensures that the data collected is accurate and that there are no omissions. It also prevents misunderstandings as well as wrong inferences and conclusions.
This is the second process in nursing, and it is concerned with further analysis and synthesis after the assessment has been done. The analysis involves the overall breakdown into sections that can be examined while synthesis is concerned with the allocation of data together in a new method. North American Nursing Diagnosis Association (NANDA) defines nursing diagnosis as a clinical judgment about personal, family, or social responses to real or potential health issues. Nursing diagnoses offer the foundation on which the selection of interventions is formulated. The rest of the nursing process of the patient care basis is delivered through this step.
There are two categories of diagnosis: medical and nursing diagnosis. The former focuses on the illness, injury, and disease process while the latter focuses on the response to real or potential implications of the client's health or life process. In establishing a nursing diagnosis, a nurse applies both critical thinking and decision-making skills. To achieve this, nurses use such questions as: 'Are their problems here?'; 'What are the possible reasons for the problem?'; 'What are the risk factors?'; and 'What data is available to answer the question?'
The following are the main types of nursing diagnosis:
- Actual diagnosis: this shows that an issue exists and comprises of the diagnostic label, related factors as well as signs and symptoms. A good example is the impaired skin integrity which is related to prolonged pressure prominence.
- Risk nursing diagnosis: this type of diagnosis shows that there is a potential problem though it has not yet presented itself. For instance, it is the risk for impaired skin integrity related to the difficulty of individual tossing and turning from side to side.
- Possible diagnosis: it shows that if appropriate preventive measures are not taken, a problem will occur.
- Wellness nursing diagnosis: it shows the patient's desire to attain a certain level of wellness in a particular functional area.
This is the third step of the nursing process. It comprises the formulation of procedures that develop the proposed outline of nursing activities in the resolution of nursing diagnosis as well as the establishment of a patient’s care plan. Planning begins after nursing diagnosis has been established and the client's strengths have been determined. The planning process involves the following four tasks:
- Prioritization of nursing diagnosis list.
- Identification of client-centered long and short-term goals and results.
- Development of specific interventions.
- Keeping the overall care plan in the client’s record.
This is the fourth stage in the nursing process. It entails the execution of the nursing care plan composed during the planning stage. In addition to this, it consists of nursing activities which have been planned to meet the objectives set with the client. This stage involves several skills, and a nurse should keep on assessing the patient’s condition before, during, and even after the nursing intervention. Reporting and documentation are other significant activities performed at the implementation stage. The information to be reported and documented includes condition before the intervention, the particular intervention, the patient's response to the intervention, and finally the client's outcomes.
This is the final stage in the nursing process. It entails determining if the patient’s goals have been attained, partially attained, or not attained at all. If the goals have been met, a nurse should determine whether nursing activities are to be stopped or continued so as to maintain the state. If the goals have been partially attained or totally not attained, a nurse should reassess the situation. Evaluation is usually an ongoing activity.
Nursing intervention refers to a treatment administered upon clinical judgment, skills, and knowledge of a nurse in order to enhance a patient's outcome. In the implementation stage, there are two types of intervention care, namely direct and indirect intervention care. Direct nursing intervention care is a treatment that is provided by engaging the client. On the other hand, indirect nursing intervention is a kind of treatment that is given away from the client although on his or her behalf.
Types of Nursing Interventions
- Nurse-initiated interventions: they are the treatments that a nurse is capable of initiating independently. For example, a nurse educating a patient for the sake of medication, its side effects, and possible disease consequences if he of she does not take the medication
- Dependent interventions: these are interventions that need an order from another health care provider like a physician. For example, a nurse reports a condition he or she cannot handle a physician who orders an antihypertensive treatment for a client. A nurse will then administer the medication as required by the physician.
- Interdependent interventions: they demand the participation of several members from the health care team. For example, apart from the order by physician above, a patient suffering from high blood pressure may reveal that he/she is on a high-sodium diet. A nurse may then include diet counseling in the patient's care plan. These interventions by different health care professionals constitute interdependent intervention.
Nursing process provides the foundation on which registered nurses can make informed judgments. In such a complex process, the application and mastering those judgments require creativity after which a certain nurse obtains relevant skills in nursing. The steps remain the same although the application and outcomes may be different in every particular situation. It is also a fundamental organizing system for the National Council Licensure Examination for Registered Nurses (NCLERN). If the desired outcomes are not achieved, a nurse has to reassess the situation by collecting data in order to determine the reason for not attaining the goals and the necessary modification of a care plan different from the previous one yielding no results. Critical thinking enables a nurse to make decisions on care priority. He or she can determine which diagnosis requires more attention over another one. Life-threatening situations are usually given the first priority although there are other several frameworks that can be used to prioritize care plan.
Part 2: Development of a Care Plan
Nursing Care Plan
As noted earlier, this stage will involve data collection, its organization, and interpretation. The data for this patient include:
- A patient is a 78-year-old man living in an assisted care living facility.
- He can walk short distances and uses a wheelchair for longer distances. He can administer his own medications and bathes himself as well.
- For the preceding year, he has been opting for sitting in his wheelchair even when being in his room.
- His previous conditions are CHF, hypertension, hyperlipidemia, and lower extremity weakness.
- Current medications include 50 mg of lepressor once a day being orally administered, 20 mg of furosemide (Lasix) once a day orally, 20 mg of Quinapril (Acupril) once a day orally, and 20 mg of atorvastatin (Lipitor) also orally administered.
This illness is termed pressure ulcer over the ischium on the right buttock. Actual diagnosis for the illness will include laboratory tests as highlighted by ANADA. The rationale for this will be in determining if there are underlying intrinsic elements. It will also be determined if there are any other medical conditions that can predispose the patient to ulcers during the slow healing period.
The data in support of this diagnosis is that the wound is oval about 10x8 mm and has red and yellow patches in the middle of it and surrounding tissue black areas. The wound also has a bad odor. This is related to prolonged pressure on bony prominence due to the patient's previous lower extremity weakness as well as hours of sitting in a wheelchair. Risk of injury would occur if this problem is not prioritized. The injury could come as a result of the formation of secretions from the wound (Jefford et al., 2013). Moreover, the patient will start feeling pain due to continued swelling and expanding of the wound. The actual diagnosis was prioritized because of the risk related to leaving the veins unattended yet the patient experiences hypertension.
Expected outcome: Methicillin-resistant Staphylococcus aureus, bacteria that are difficult to treat was identified in many antibiotics of a human. The psychomotor outcome was identified evidenced by the fact that the patient could administer his own medications even when there is a change in the previous medications. In other words, he can learn and follow directives or prescriptions.
At this point, a nurse should continue to assess the client’s state after the intervention. The assessment is done before intervention offered a nurse such basic data as his previous diseases: hypertension, hyperlipidemia, CHF, and lower extremity weakness. Assessment done during and after the intervention will enable a nurse to detect either positive or negative responses that the patient will have developed as an intervention result. When the results are positive, a nurse will indicate this in a database, otherwise, he or she should take appropriate actions. In the implementation stage, a nurse will be expected to possess interpersonal, critical, and psychomotor skills considering the patient, in this case, is 78-year-old. All the information is documented in reports at this stage.
At this point, a nurse should determine whether the goals have been achieved, partially achieved, or not achieved completely. If the wound has shown signs of recovery and has stopped producing bad odor, a nurse will record this as a partial recovery. Since evaluation is an ongoing process, he/she should follow up later to determine if the wound heals completely. If after the follow up there are no signs of recovery, the reassessment should be done again.
These are nurse-initiated interventions. As discussed in part one, nurse-initiated intervention is an independent action centered on a scientific rationale which a nurse performs to benefit the client in a predictable manner considering the nursing diagnosis and projected outcomes. In this case, the independent or nurse-initiated intervention will be suitable in the reducing liquid that was coming out of the patient's wound. This will reduce further swelling of the wound and maintain the patient's health status.
Dependent intervention is also called physician-initiated intervention because it is a situation when a nurse is responding to a doctor’s orders. In this case, the nurse decision is referred to the patient for admission and for further initiation of intravenous antibiotic therapy and wound care.
Interdependent intervention is also called a collaborative intervention. It involves treatment subscribed by different health care teams such as pharmacists, therapists, and physician assistants, among others. In this case, the medication must have been sought from a pharmacist while a therapist was consulted about the intravenous antibiotic therapy.
Part 3: Development of a Teaching Plan
Patient teaching is a system of activities aimed at producing learning that helps the patient to meet personalized learning goals. In case they do not, the patient's requirement should be reassessed, and the actions replaced by others. In this case, the information alone will not help this client in taking his medications. Actual showing him how the medicines are taken in order will be more effective. Patient teaching is an active relationship between a teacher (nurse) and a learner (patient) where two stakeholders communicate information, attitudes, perceptions as well as emotions to each other.
Prior to the preparation of the teaching plan, the registered nurse (RN) should:
- Assess the patient’s learning needs by reviewing his medical records.
- Identify the attitude and knowledge required by the client and divide the learning into a psychomotor, cognitive, and effective one.
- Assess the patient’s both emotional and experiential readiness to learn. The RN should put in mind that readiness and ability are not the same.
- Assess whether the client has the ability to learn because the teaching method ought to be appropriate to his developmental stage.
- The RN should also know the time limits or the schedule of the patient before preparing the teaching plan.
In determining the learning plan format, the RN will consider the following issues:
- The patient’s basic and preferred mode of communication, whether verbal or written.
- The patient’s ability to comprehend spoken words.
- The patient's most preferred language for both verbal and written communication. This is significant because there are patients who can speak a language perfectly but cannot read the same language effectively. Furthermore, since most discharged self-care and follow up information are done through written communication, the RN should ensure that the patient can read it. If not, the caretaker at the living facility should be informed to offer reading support.
- The patient’s ability to comprehend written words, gestures, or pictures is also a very significant consideration.
The RN determines the information to be included in the learning plan after assessing and comprehending the patient’s preferred mode of communication, the environment of the living facility that the patient is living in , the purpose for which the leaning is aimed for, and the general requirements of the patient that will lead to the intended outcome. In this case, the learning aims at improving the health status of this man. After the therapy and wound treatment, the nurse aims at educating the patient how to take care and use the prescribed medication. With such knowledge, RN will, for example, indicate in the learning plan even a walk for a few meters after every 2 hours in order to facilitate the rate at which blood flows in veins. As far as the environment at the living facility center is concerned, RN may indicate and should indicate in the learning plan that the patient should be checked at night by the caregiver for taking medication since the nurse is not present at the center. The assessment test indicates that the patient sits in a wheelchair for a long time. The learning plan should indicate that the moment the patient is in his room, he should try and sleep or sit in a different chair since the constant sitting in the same position in a wheelchair may have caused the swelling of the wound.
When and How to Evaluate the Teaching-Learning Process
After the preparation of the teaching-learning plan, RN has to evaluate it. Evaluation is done during and after the teaching-learning process. It is also using the following ways.
Firstly, observing the client determine whether he is putting the information learned into practice. RN should check to see if the patient changes his sitting position as opposed to sitting in his wheelchair all day long.
Secondly, the RN should ask him direct questions to determine his level of knowledge as far as his condition is concerned. For instance: 'Are you feeling today better than yesterday after sitting less time?'
Thirdly, listening to the patient's comments will enable the RN to evaluate the level of understanding the things he was taught.
Finally, a return demonstration will also be a significant thing. For instance, a nurse should ask the client to repeat the procedure of sitting postures as it was demonstrated.
In this paper, the nursing process has been extensively evaluated. Right from assessment, diagnosis, planning, implementation to evaluation, the paper has explained what each of these issues involves in part one and applied them in situation-based analysis in part two. In the second part, the nursing plan for a patient has been applied to give a clear view of the whole nursing process. The paper has also defined various types of nursing interventions as well as their difference in the application of them. Nurse-initiated intervention is an independent action centered on a scientific rationale which a nurse performs to benefit the client in a predictable manner considering the nursing diagnosis and projected outcomes. The dependent intervention also called a physician-initiated intervention, occurs when there is an order from another healthcare provider like a physician. Interdependent intervention is also called a collaborative intervention. It involves treatment subscribed by different healthcare teams such as pharmacists, therapists, and physician assistants, among others. Therefore, this paper has comprehensively covered the nursing process, nursing plan development, and its application in the situational analysis.