Running head: NURSING PROCESS Nursing Process University of Phoenix Nursing Process In the field of nursing, the nursing process is a vital tool used to promote appropriate and effective nursing care to patients. The actual nursing process consists of five components, which are intermingled, and constantly adjusting or changing according to the patients needs. The Registered Nurse (RN), regardless of the area of nursing being practiced, utilizes the nursing process to effectively deliver patient-focused care (American Nurses Association, 2006) (Kuckyt, 2008).
The assessment phase includes the gathering of facts. The information obtained includes psychological, physiological, and sociocultural data, as well as economic and life-style factors, which can all effect the patients’ recovery (American Nurses Association, 2006) (Kuckyt, 2008) (Quan, 2007). During this fact-finding phase, the RN obtains information from what he or she observes directly via a physical assessment as well as information obtained from other sources such as the patient, patient family, and laboratory or test results.
This information is vital and essential before continuing through the remaining four phases of the Nursing Process and establishing an effective plan of care. For example, while obtaining a medical history from a Ketoacidosis patient, the nurse discovers the patient has had no formal teaching regarding the disease and a lack of financial resources. During the diagnosis phase, the RN is able to elaborate beyond the obvious clinical diagnosis determined by the physician.
The RN uses the data obtained during the assessment phase as well as his or her critical thinking skills, to determine additional problems, which can determine the patients’ response to treatment (Ackley, 2008). The actual nursing diagnoses are included in a system named “The North American Nursing Diagnosis Association” or NANDA. The RN chooses an approved diagnosis from the NANDA list related to his or her patient. For example, using the previously mentioned patient, the nurse establishes a NANDA approved diagnosis of “Deficient Knowledge” and include a defining characteristic of verbalization of the problem with a related actor of unfamiliarity with information resources. NANDA consists of accepted diagnosis employed by nurses and includes suggested nursing outcome classification (NOC) as well as suggested nursing intervention classifications (NIC) (Ackley, 2008). The planning phase of the nursing process includes the formulating and establishing measurable outcome or goal statements and determines appropriate nursing interventions utilizing both NOC’s and NIC’s (Ackley, 2008) (Blias, 2006).
For the Ketoacidosis patient, appropriate NOC’s include knowledge of diet in four days, knowledge of disease process in seven, as well as medication knowledge in 5 days and health resources knowledge in seven days. A time limit for accomplishing each NOC must also be included. The goals included in the planning phase of the nursing process are patient oriented not nursing oriented. The goals must address patient needs not nursing needs (Quan, 2007).
The fourth phase of the nursing process includes individualized interventions (NIC’s) established to provide the best care for the patient and reach the goals established (Ackley, 2008) (Quan, 2007). Appropriate NIC’s for the Ketoacidosis patient may include teaching of the disease process and medications verbally and with reading material, as well as intervention from dietician. Additional NIC’s for this patient could include an individualized discussion and introduction of community health resources available for further education and financial assistance needed by this patient (Ackley, 2008).
Documentation of each intervention listed is essential. The intervention phase of the nursing process is when the nursing care plan actually commences and the nurse constanty evaluates the success of the interventions used (Quan, 2007) (Ackley, 2008) (Blias, 2006). The evaluation phase is technically listed as the last one included in the nursing process; however, this phase is evident throughout the entire process and included in each phase. The RN, during this phase, determines the success or failure of the interventions in accordance to the success or failure of meeting the NOC’s.
Failure to meet the NOC’s will result with another assessment to determine cause of the failure. This evaluation may determine an error in initial diagnosis or a need to change the interventions used. For example, regarding the Ketoacidosis patient, the patient continues to have a deficit in disease knowledge and the nurse determines via the second assessment, this patient has a reading disability thus was unable to utilize the literature given. The intervention list would need to be adapted to the learning needs of the patient and include more verbal and illistrated information rather than just words.
As the RN travels from one phase to another, he or she is constantly evaluation the effectiveness or response of the patient to each phase (Kuckyt, 2008) (Quan, 2007) (Ackley, 2008). As the RN gains experience, he or she is able to quickly move from one phase to another or even skip phases according to previous knowledge and experience. The nursing process is evident and used within Orem’s Self-Care Theory (Dennis, 1997). Orem’s theory focuces on the goal of self care for the patient and includes three basic steps or phases (Dennis, 1997).
The first step, Diagnosis and prescription, like the assessment and diagnosis phases of the nursing process includes the collection of data which enables the nurse to determine variables involved and establishes self care demands for a specific patient. The second step in Orem’s self-care theory involes designing and planning a course of action to promote self care status for the patient and very much resembles the planning phase of the nursing process. The data collected in the initial step is used to establish a unique plan of care addressing specific patient needs.
The third and final step is listed as regulate and control. This step mirrors the implementation and evaluation phase of the nursing process. During this step, the nurse actually implements nursing care and continuously evaluates effectiveness of the care given in reference to the accomplishment of the final goal (Blias, 2006) (Dennis, 1997). Orem’s theory especially corresponds with the nursing intervention phase in that both facilitate the re-establishment of self care capacity for the patient. Within Orem’s theory are three types of nursing systems.
In the wholly compensatory system the nurse completes the actions needed to accomplish patient care. Within the partly compensatory system both the nurse and the patient work together to accomplish the patient care needed. The supportive-educative system is optimal, with the patient accomplishing his or her own self-care and the nurse in a supportive role promoting or regulating the self care (Dennis, 1997). The nursing process and Orem’s theory can be applied simutaneously to effectively promote patient care.
While very similar, the Orem’s theory expands on the basic nursing process with a focus on self care with active patient involvement in care decisions rather than passive involvement as the recepient of care given. References: Ackley, B. a. (2008). Nursing Diagnosis Handbook-An Evidence-based Guide to Planning Care (Vol. 8). St. Lous: Mosby. American Nurses Association. (2006, nd nd). The Nursing Process: A Common Thread Amongst All Nurses. Retrieved September 26, 2009, from American Nurses Association: http://www. nursingworld. org/EspeciallyForYou/StudentNurses/Thenursingprocess. spx Blias, K. E. (2006). Professional Nursing Practice:Concepts and Perspectives(5th ed. ). Upper Saddle River: Pearson Education Inc. Dennis, C. (1997). Self-Care Deficit Theory. St. Louis: Mosby. Kuckyt, C. (2008, November 20). Nursing Process & Critical Thinking. Retrieved September 27, 2009, from Nursing Process & Critical Thinking: http://home. cogeco. ca/~nursingprocess/index. htm Quan, K. (2007, nd nd). The Nursing Process. Retrieved September 26, 2009, from The Nursing Site: http://www. thenursingsite. com/Articles/the%20nursing%20process. htm