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Assessment and diagnosis

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Abstract

In the following document I will discuss Plan, implement, and evaluate components of the nursing process at length. I will define the plan, implement, and evaluation in the nursing care process. While showing how it is used in the nursing field.

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Plan, Implement and Evaluation

The nursing process is an organizing framework for professional in the nursing practice. It is the critical thinking process for the nurse to utilize to give the best care possible to the client. It is very similar to the steps used in scientific reasoning and problem solving.

Main components of the process include these steps of the nursing process known as ADPIE. A stands for assess which is performing a nursing assessment. D stands for diagnosis, P stands for the care plan, I stand for implementing the care plan and E stands for evaluating the outcome. In this following document I will go more in depth and discuss the last three steps. Let’s start with Planning.

Planning in the nursing care plan involves identifying the priorities as well as determining the client specific outcomes and interventions. The nurse must determine the urgency of the identified problems and prioritize the patient needs. Nursing diagnoses should be prioritized first by immediate needs based on airway, breathing, and circulation. The highest priority can and should by determine by using the Maslow’s hierarchy of needs. In the Maslow’s hierarchy, priority is given to most severe problems that may be life threatening.

The planning should be done, when possible with the client and their family to increase efforts and understanding. This also helps the compliance with the proposed plan and outcomes, which increase a positive result to the patients care. Writing a proposed plan and outcomes statement, it is best to make sure it is SMART, which means: specific, measurable, attainable, realistic, and timed. Once this is done, the outcomes for the patients should be easily established. Based on the patient’s story, the nursing assessment, the mutual goals and outcomes, the nurse should be able to prioritize his or her work. The nurse should then decide what intervention to use which is based on clinical judgment and knowledge. The nurse should involve the client and/or family in determining appropriate outcomes. The patient’s outcomes are chosen, written and discussed with the patient, then the nursing care is fully planed and established that will help with the outcomes which leads to the interventions. Interventions are directing the best way to provide nursing care, the more descriptive the interventions is, the easier it will be to get the desired outcome. Interventions can be independent or collaborative. The nurse chooses the best interventions for the patients and customizes it to the patient. The plan must be documented and shared with all health care personnel caring for the patient. Once this is done the nurse can start the Implementation process to the nursing care plan. The implementation phase is basically the carrying out phase. This phase focuses on alleviating symptoms so that the client or patient can function at their highest level. While performing the interventions, make sure that it is appropriate for the patient.

The outcomes are gain by the performance of the nursing interventions in collaboration with the patient and their family. During the implementation phase the nurse should continue to assess the client to determine whether the interventions are positive and is the desired outcomes. The last phase of the nursing process is thee evaluation process. Evaluation is in a sense another assessment, hence the dynamic feature of the nursing process. The evaluation determines if the patient care plan needs to be altered or not. The nurse should use the facility’s tool for documentation and record the nursing activity that was performed and results of implanting nursing interventions. Many facilities used problem oriented charting, in which the nurse evaluates the care and the patient’s outcomes as a part of the charting. Documentation is necessary for legal reasons because in a legal dispute, if it wasn’t charted or recorded, then it wasn’t done. Many nurses are using critical pathways or care maps to plan nursing care. The use of nursing diagnoses should be a part of any critical care plan to ensure that nursing care needs are being met. In Summary PIE refers to planning, implementing and evaluating. Planning determines the appropriate outcome and interventions for the patient. Implementing is the point at which you actually give the nursing care. Evaluating is basically a reassessment to determine accurate care plan was used and patient had a positive outcome.

References
Ackley, B. J. (2012). nursing diagnosis handbook. Missouri: wiley. Jacob, C. (2014). Contemporay Nursing. Missouri: Elsevier.
T.O’Toole, M. (2013). Mosby’s dictionary of medicine, nursing adn health professions. Missouri: Mosby.

To summarize the knowledge I have gain and discuss in this document about assessment and diagnosis in the nursing care process is to make sure you collect accurate information in the patient story. Also to gather information from family and to organize information from most important to least, to make the most appropriate diagnosis for the patient care. When diagnosis is made be sure to label the diagnosis accurately and to follow the NANDA-I guidelines in providing a proper diagnosis for the client. I hope this document have made you more aware on the assessment and diagnosis process in the nursing care plan and what it is define as and how it is used to provide care to patient in today’s world.

Cite this Assessment and diagnosis

Assessment and diagnosis. (2016, Aug 18). Retrieved from https://graduateway.com/assessment-and-diagnosis/

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