INTRODUCTION
Nursing is a healthcare profession focused on the care of individuals, families, and communities, so they may attain, maintain, or recover optimal health and quality of life from conception to death.
Nurses work in a large variety of specialties where they work independently and as part of a team to assess, plan, implement and evaluate care. Nursing Science is a field of knowledge based on the contributions of nursing scientists through peer-reviewed scholarly journals and evidence-based practice.
Nursing process
The nursing process is a modified scientific method. Nursing practice was first described as a four stage Nursing process by Ida Jean Orlando in 1958. It should not be confused with nursing theories or health informatics. The diagnosis phase was added later.
The nursing process uses clinical judgment to strike a balance of Epistemology between personal interpretation and research evidence in which critical thinking may play a part to categorize the clients issue and course of action. Nursing offers diverse patterns of knowing. Nursing knowledge has embraced pluralism since the 1970.
Characteristics of the nursing process
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 centered
- Interpersonal and collaborative
- Universally applicable
- Systematic.
Phases of Nursing Process
- Assessing phase
- Diagnosing phase
- Planning phase
- Implementing phase
- Evaluating phase.
Assessing Phase: Nursing Assessment
The nurse completes an wholistic 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.
Method for data collection
Nursing assessments provide the starting point for determining nursing diagnoses. 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.
Collecting data
- Client interview
- Physical examination
- Obtaining a health history (including dietary data)
- Family history/report
- Diagnostic data
- Observation
Diagnosing Phase
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses are developed based on data obtained during the nursing assessment.
The primary organization for defining, dissemination and integration of standardized nursing diagnoses worldwide is NANDA—International Formerly known as the North American Nursing Diagnosis Association. For nearly 40 years NANDA-1 has worked in this area to ensure that diagnoses are developed through a peer-reviewed process requiring standardized levels of evidence, standardized definitions, defining characteristics, related factors and/or risk factors that enable nurses to identify potential diagnoses in the course of a nursing assessment. NANDA-1 believes that it is critical that nurses are required to utilize standardized languages that provide not just terms (diagnoses) but the embedded knowledge from clinical practice and research that provides diagnostic criteria (definitions, Assessment) and the related or etiologic factors upon which nurses intervene. NANDA-1 terms are developed and refined for actual (current) health responses and for risk situations, as well as providing diagnoses to support health promotion. Diagnoses are applicable to individuals, families, groups and communities.3
Planning Phase
In agreement with the client, the nurse addresses each of the problems identified in the diagnosing phase. When there are multiple nursing diagnoses to be addressed, the nurse prioritizes which diagnoses will receive the most attention first according to their severity and potential for causing more serious harm. For each problem, a measurable goal/outcome it 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.
Implementing Phase
The nurse implements the nursing care plan, performing the determined interventions that were selected to help meet the goals/outcomes that were established.
Evaluating Phase
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.
The entire process is recorded or documented in order to inform all members of the health care team.