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.
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