NAME 

           : Bamey Ganado

SEMESTER   : 2nd SEMESTER,2023
COURSE        : HUMAN BIOLOGY BL133
 

The Nursing Process in Medical-Surgical Nursing: A Comprehensive Guide

I. Introduction

The nursing process is a systematic and organized approach used by nurses in providing patient-
centered care. It is an essential tool in medical-surgical nursing, which involves the care of
patients who are acutely or chronically ill with medical conditions that require surgical
intervention. The nursing process involves five key phases: assessment, diagnosis, planning,
implementation, and evaluation. Each phase builds upon the previous one and guides nurses in
developing an individualized plan of care for each patient. The nursing process is critical in
ensuring that patients receive safe, effective, and high-quality care.

II. Assessment Phase

The assessment phase is the first step of the nursing process and involves gathering information
about the patient's health status, history, and current condition. In medical-surgical nursing,
assessment is crucial in identifying the patient's surgical and medical history, current
medications, allergies, vital signs, and laboratory results. The nurse also evaluates the patient's
physical, psychological, social, and cultural status.

There are three types of assessments that nurses use in medical-surgical nursing: initial, focused,
and ongoing assessments. The initial assessment is performed upon admission, and it involves
collecting data about the patient's overall health status. The focused assessment is performed
when the patient's condition changes, and the nurse focuses on specific body systems or issues.
Ongoing assessment involves monitoring the patient's progress and making adjustments to the
care plan as needed.

Nurses use various assessment tools and techniques in medical-surgical nursing, such as physical
examination, diagnostic tests, and patient interviews. The physical examination involves
observing, palpating, percussing, and auscultating the patient's body to assess physical health
status. Diagnostic tests, such as blood tests, X-rays, and CT scans, provide objective data about
the patient's condition. Patient interviews allow nurses to gather subjective information about the
patient's health status, including symptoms and concerns.

In conclusion, the assessment phase is critical in medical-surgical nursing as it provides the

foundation for the rest of the nursing process. Through a thorough and comprehensive
assessment, nurses can develop an individualized care plan that meets the patient's unique needs.

III. Diagnosis Phase

NAME            : Bamey Ganado
SEMESTER   : 2nd SEMESTER,2023
COURSE        : HUMAN BIOLOGY BL133
 

The diagnosis phase is the second step of the nursing process and involves analyzing the data
gathered during the assessment phase to identify the patient's health problems. In medical-
surgical nursing, nursing diagnosis plays a crucial role in identifying actual and potential health
problems that require surgical intervention.

There are three types of nursing diagnoses: actual, risk, and wellness. Actual nursing diagnoses
identify existing health problems that require nursing intervention. Risk nursing diagnoses
identify potential health problems that may develop in the future, while wellness nursing
diagnoses focus on promoting and maintaining optimal health.

Nursing diagnosis is formulated using a problem-focused or a risk-focused approach. The

problem-focused approach identifies the patient's health problems and their associated signs and
symptoms. The risk-focused approach identifies potential health problems and factors that
increase the patient's risk of developing them.

Nurses use standardized nursing language, such as the North American Nursing Diagnosis
Association International (NANDA-I) taxonomy, to formulate nursing diagnoses. A nursing
diagnosis statement consists of three parts: the problem, the etiology, and the defining
characteristics.

In conclusion, the diagnosis phase is a critical step in medical-surgical nursing as it identifies the
patient's health problems, which are used to develop an individualized plan of care. Nursing
diagnosis helps nurses to focus on the patient's specific needs and provide targeted interventions
to achieve optimal health outcomes.

IV. Planning Phase

The planning phase is the third step of the nursing process and involves developing a plan of care
for the patient based on the identified nursing diagnoses. In medical-surgical nursing, planning is
critical in ensuring that the patient receives appropriate interventions before and after surgery.

The planning phase involves setting priorities, establishing patient-centered goals, and
developing interventions to address the identified nursing diagnoses. Prioritization is based on
the urgency of the nursing diagnoses and the patient's condition. Patient-centered goals are
specific, measurable, attainable, relevant, and time-bound (SMART) and should be developed in
collaboration with the patient, family, and healthcare team.

The nursing care plan includes interventions that address the patient's physical, psychological,
social, and cultural needs. These interventions are based on evidence-based practice and may
include medication administration, wound care, pain management, education, and discharge
NAME            : Bamey Ganado
SEMESTER   : 2nd SEMESTER,2023
COURSE        : HUMAN BIOLOGY BL133
 

planning. The nursing care plan also includes contingency plans for unexpected events, such as
surgical complications.

In medical-surgical nursing, there are two types of planning: short-term and long-term planning.
Short-term planning focuses on the immediate needs of the patient and aims to achieve goals
within hours to days. Long-term planning focuses on the patient's needs beyond the immediate
postoperative period and aims to achieve goals within weeks to months.

In conclusion, the planning phase is essential in medical-surgical nursing as it guides the nurse in
providing patient-centered care that meets the patient's specific needs. Through effective
planning, nurses can ensure that the patient receives appropriate interventions that promote
healing, prevent complications, and optimize health outcomes.

V. Implementation Phase

The implementation phase is the fourth step of the nursing process and involves carrying out the
interventions specified in the nursing care plan. In medical-surgical nursing, implementation
involves the delivery of safe and effective care to patients before, during, and after surgery.

Implementation includes a range of interventions, such as medication administration, wound

care, patient education, and pain management. The nurse should prioritize interventions based on
the patient's needs, and the interventions should be consistent with the nursing diagnosis and the
care plan.

In medical-surgical nursing, the nurse works in collaboration with the interdisciplinary team,
including the surgeon, anesthesiologist, physical therapist, and social worker, to provide
comprehensive care to the patient. The nurse should communicate effectively with the team and
ensure that the interventions provided are consistent with the overall plan of care.

Documentation is a critical aspect of the implementation phase. The nurse should document all
interventions provided, including the time and date, the response of the patient, and any adverse
reactions or complications. Documentation should be accurate, timely, and in compliance with
the legal and ethical standards of nursing practice.

In conclusion, the implementation phase is crucial in medical-surgical nursing as it involves the

delivery of safe and effective care to patients. Through effective implementation, nurses can
ensure that the patient receives appropriate interventions that promote healing, prevent
complications, and optimize health outcomes.

VI. Evaluation Phase

NAME            : Bamey Ganado
SEMESTER   : 2nd SEMESTER,2023
COURSE        : HUMAN BIOLOGY BL133
 

The evaluation phase is the fifth and final step of the nursing process and involves determining
the effectiveness of the interventions provided to the patient. In medical-surgical nursing,
evaluation is essential in determining whether the patient's health outcomes have been achieved.

Evaluation involves comparing the patient's actual outcomes with the expected outcomes
specified in the nursing care plan. The nurse should use objective and subjective data to evaluate
the effectiveness of the interventions provided, such as vital signs, laboratory results, and patient
feedback.

If the expected outcomes have been achieved, the nursing care plan may be revised to reflect the
patient's changing needs. If the expected outcomes have not been achieved, the nurse should re-
evaluate the nursing diagnosis and the care plan and make appropriate revisions.

The nurse should also evaluate the patient's response to the interventions provided, including any
adverse reactions or complications. If adverse reactions or complications have occurred, the
nurse should document them and report them to the interdisciplinary team.

Documentation is a critical aspect of the evaluation phase. The nurse should document the
patient's actual outcomes, including any changes in the patient's condition, the response to
interventions, and any adverse reactions or complications. Documentation should be accurate,
timely, and in compliance with the legal and ethical standards of nursing practice.

In conclusion, the evaluation phase is critical in medical-surgical nursing as it determines the

effectiveness of the interventions provided and ensures that the patient's health outcomes have
been achieved. Through effective evaluation, nurses can revise the nursing care plan, provide
appropriate interventions, and optimize health outcomes.

VII. Conclusion

In conclusion, the nursing process is a systematic approach used by nurses to provide patient-
centered care in medical-surgical nursing. The nursing process includes five steps: assessment,
diagnosis, planning, implementation, and evaluation.

The assessment phase involves gathering information about the patient's physical, psychological,
social, and cultural needs. The diagnosis phase involves identifying the patient's health problems
and developing nursing diagnoses. The planning phase involves developing a plan of care based
on the identified nursing diagnoses. The implementation phase involves carrying out the
interventions specified in the nursing care plan. The evaluation phase involves determining the
effectiveness of the interventions provided to the patient.
NAME            : Bamey Ganado
SEMESTER   : 2nd SEMESTER,2023
COURSE        : HUMAN BIOLOGY BL133
 

In medical-surgical nursing, the nursing process is critical in ensuring that patients receive
appropriate interventions before, during, and after surgery. Through effective use of the nursing
process, nurses can provide safe and effective care that promotes healing, prevents
complications, and optimizes health outcomes.