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The Nursing Process

The Nursing Process

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Published by Deepak Sharma

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Published by: Deepak Sharma on Mar 06, 2012
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The Nursing Process

The nursing process is based on a nursing theory developed by Ida Jean Orlando. She developed this theory in the late 1950's as she observed nurses in action. She saw "good" nursing and "bad" nursing. From her observations she learned: The patient must be the central character Nursing care needs to be directed at improving outcomes for the patient; not about nursing goals The nursing process is an essential part of the nursing care plan Not As Complicated as it Seems The nursing process is really not as complicated as it seems. It consists of basically five steps. Originally, Ms. Orlando had four, but through practical application over the past 40 years, one step evolved into two and now there are five. All nursing personnel take part in the nursing process. The RN has the primary responsibility however. The Five Steps Assessment Diagnosis Planning Implementation Evaluation Assessment This is the data collection step. For RNs it also entails analyzing the data and possibly making a more complex and in-depth assessment based on the findings. LPNs, CNAs and all non-licensed nursing personnel are not trained in analyzing data. This gives rise to statements that "LPNs cannot

Once you have identified the patient's problems related to his health status. the process moves on to analysis of the data to determine the health status. It involves asking pertinent questions about his signs and symptoms. but to also understand and adhere to their job description and/or scope of practice. you formulate a nursing diagnosis for each of them. they just don't complete the second portion of that step. Assessment involves taking vital signs.assess patients". Once you have collected the data. listening to the patient's comments and questions about his health status. performing a head to toe assessment. except in the case of Nurse Practitioners who have been trained and licensed to make medical diagnoses. Diagnosis Nurses only make nursing diagnoses. and listening carefully to the answers. It is important for LPNs as well as CNAs and non-licensed nursing personnel to understand the nursing process. . You will also prioritize the problems in formulating your plan and goals. analysis. his ability to use these mechanisms and to identify his problems related to his health status. the patient's coping mechanisms or lack thereof. They may not make any independent decisions about the patient's plan of care. observing his reactions and interactions with others. In truth they do asses.

what are the expectations for this patient? This not about nursing goals. It can even be a problem that relates to his family rather then to him alone such as the family's inability to cope with life style changes necessitated by the patient's illness. this will become more clear. Planning Setting goals to improve the outcomes for the patient is a primary focus of the nursing process. NANDA adopted the current classification system (known as a taxonomy) as Taxonomy II. most patients will have more than one problem to diagnose and address. In 2000. Based on the nursing diagnoses. and the nurse has to adapt to these changes. The RN chooses a nursing diagnosis from the NANDA list which most closely describes the patient's problem related to his health status. The North American Nursing Diagnosis Association (NANDA) has now become an international group who works to classify nursing diagnoses. They are patient goals. In fact. As they begin to understand and utilize the nursing process. There are 13 domains which are subdivided into 106 classes and 155 nursing diagnoses. This is about what your patient needs to do to improve his . This is about improving the health status and quality of life for your patient. and to review and accept new diagnoses as needed. This is often difficult for students and new nurses to grasp. This priority can change. This might be a current problem or a potential problem which needs to be addressed.Nursing Diagnosis The nursing diagnoses are categorized by a system commonly referred to as NANDA. The severity of the problem and how it is effecting patient outcomes will determine the priority for that problem.

For example: "after instruction insulin therapy. Planning also involves making plans to carry out the necessary interventions to achieve those goals.health status and/or better cope with his illness. . but examining the need for adjustments and changes as well. The use of formal care plans or care maps and protocols is highly advised. Evaluation leads back to Assessment and the whole process begins again. All members of the health care team should be informed of the patient's status and nursing diagnosis. Communication is essential to the nursing process." Implementation Implementation is setting your plans in motion and delegating responsibilities for each step. Evaluation involves not only analyzing the success (or failure) of the current goals and interventions. The evaluation process incorporates all input from the entire health care team. They are also responsible to report back to the RN all significant findings and to document their observations and interventions as well as the patient's response and outcomes. including the patient. the goals and the plans. the patient will successfully return demonstrate the ability to accurately draw up the insulin by Monday and safely self inject by Tuesday. Evaluation The nursing process is an ongoing process.

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