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“The assessment phase of the nursing process is foundational for appropriate diagnosis, planning and ,” (Ackley & Ladwig, 2014, p3).
This beginning phase of the nursing process is important for many reasons. Not only are we meeting our patients for the first time but we collect but object and subjective data to put together and create a picture of our patient. The nurse makes an assessment of the patient, utilizing all the information that is gathered and can better understand their needs. Each nurse, through time and practice, fine tunes these assessment tools needed to go even further into a patients needs such as the holistic approach of mind, body and spirit.
Assessment information gathering is done by looking at the patient’s chart, discussing with the patient about their history, and even through communication with the family members.
The subjective date we can gather from the patient and family can help us understand how they are feeling or thinking. A thorough health and medical history are important so that we can implement the best care designed specifically for that patient.
The physical assessment is also important; this gives us objective information regarding the patient’s current vitals signs, physical head to toe and any diagnostic’s previously done or that need to be completed. The information that gathered in this phase helps create the next phase which is formulating a nursing diagnosis.
“In the diagnosis phase of the nursing process, the nurse begins clustering the information within the client story and formulating and formulates an evaluative judgment about a client’s health ,” (Ackley & Ladwig, 2014, p3). After a nurse gathers all the subjective and objective information about the patient alone with using their knowledge, we formulate a diagnosis using “NANDA,” “North American Nursing Diagnosis Association.” There is a list of nursing diagnosis related to primary clinical issues and may or may not have secondary issues too. The patient may also have many different diagnosis’ that need to treat as well, so the gathering information phase prior to the diagnosis phase is paramount. “ A working nursing diagnosis may have two or three parts. The two-part system consists of a nursing diagnosis and the ‘related to’ (r/t) statement….
“The three-part system consists of a nursing diagnosis. The ‘related to’ (r/t) statement and the designing characteristics, which are observable cues/inferences that cluster as manifestations of actual or wellness nursing diagnosis” (Ackley & Ludwig, 2014, p4). This three-part system helps the nurse understand the primary diagnosis and the symptoms involved and what those symptoms may be related to. Creating a nursing diagnosis takes into consideration all data collected, other health issues (chronic or acute), symptoms that need to be treated and taking it all in with a holistic approach as a nurse.
The Outcomes / Planning Phase
According to King (1997), In this phase the nurse is able to use the prior steps of the nursing process and build off of it for the Outcome/Planning phase. The nurse formulates a course of action based on the her assessment and nursing diagnosis. The nurse uses her critical thinking abilities to prioritize and develops specific nursing interventions and documents her plan accordingly.
The implementation phase of the nursing process is the stage where the nurse can put her nursing assessment to action. The Nurse Intervention Classification or NIC, is a system that defines nursing interventions and clusters them into families of therapies and treatments that gear toward a specific problem. According to Forbes, “Nursing requires robust clinical research to show that its interventions do not harm and have a beneficial effect.” In this vital stage of the nursing process, there is a certain level of knowledge needed effectively to accomplish a positive outcome for the patient. At this point, a substantial amount of scientific knowledge is also needed so to understand how the interventions that are chosen, will impact the outcome for the patient. (Forbes, 2009) The knowledge needed at this point are as follows:
•Nurse must be able to understanding the medical knowledge of the diagnosis and how it impacts the patient’s physical and psychosocial functions •Nurse must be able to determine if the intervention will produce the desired outcome for the patient based on scientific research. •Nurse must know what equipment or resources needed for the chosen intervention •Nurse must know the patient’s current status , to be sure the intervention is still relevant •Nurse must be aware of patient’s spiritual and culture needs that may potentially hinder the interventions outcome. •Nurse must know what evidence will determine the effectiveness of the intervention
The nursing knowledge is needed and describes the scientific basis of nursing knowledge. Evaluation is defined as the judgment of the effectiveness of nursing care to meet the patient’s goals. According to King (1997), in this step of the nursing process the nurse compares the patient’s behavioral responses with predetermined patients goals and outcome criteria. Evaluation is the final step in the nursing process. Although evaluation is the final step in the nursing process, it has concurrently run throughout all phases of the nursing process. The nursing knowledge that is needed in the Evaluation step of the nursing process in: Nurses must be able to identify criteria and standards. Nurses must be able to evaluate collected data. Nurses must be able to interpret and synthesise data. Nurses must be able to document findings and identify when goals are met, or when to revise, update, change or complete the care plan.
(2014). In B. J. Ackley, & G. B. Ladwig, Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care, Tenth Edition. Missouri: Mosby. Forbes, A. (2009). Clinical Intervention Research in Nursing . International Journal of Nursing Studies, pg 557-568. King JA, Morris LL, Fitz-Gibbon CT. How to Assess Program Implementation
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