Nursing Process

1 Nursing Process Date: 03/17/2022 2 Background: History and Evolution of Nursing Process The nursing process is a constructed professional framework utilized by the nurses to provide quality patient care within healthcare facilities. The process is critical in assisting nurses in achieving health promotion goals, preventing illnesses, and attaining health protection for their clients. Critical thinking is relied upon by the nursing process, and thus, the nurses utilize the framework maximally to achieve their nursing care goals. Lydia Hall acknowledged the nursing process first in 1960, which comprised three key steps; assessment, planning, and assessment (Movlavi et al., 2019). Later, Yura and Walsh developed the nursing process into four steps adding the implementation phase. In 1973, The American Nurses Association (ANA) constructed the Standards of Practice. The nursing process was identified with an inclusion of the nursing diagnosis. The North American Nursing Diagnosis Association (NANDA) in 1974 emphasized that the diagnosis step to be distinct, which was initiated merged in the Assessment phase. Most of the states revised their nursing practice. Later in 1991, outcome identification was an additional step within the nursing process at the planning phase. This led to today's international five-step nursing process; Assessment, Diagnosis, Planning, Implementation, and Evaluation (Movlavi et al., 2019). 3 Overview of the Nursing Process Assessment The assessment is the initial step in the nursing process which involves data gathering through interviews with the client (D’Agostino et al., 2018). The nurse interrogates the client, collects both subjective and objective data during this step. Information collected is related to psychological, physical, physiological, and sociological needs. The nurse initiates assessment by creating the nurse-patient relationship important for comprehensive medical history. During this phase, physical examinations, health history, past medication, allergies, environmental history, and genetic factors are used to gather information. Nursing assessment can be focused, emergency, or lapsed. Subjective data involves the client's point of view, which could include headache, nausea, or abdominal pains. Objective data is measured, such as the blood pressure or observed by the nurses, and this could consist of the laboratory examination. Examples of subject data can be hypertension, proteinuria, or tachycardia. Nursing Diagnosis The assessment gathered data would formulate a dependable nursing diagnosis that depends on the nursing judgment. The nursing diagnosis is focused on the client's problems and comprises three standard parts: problem, etiology, and the defining characteristic. Employment of Maslow's Hierarchy of Needs will be emphasized to address the most critical patient needs (Santana et al., 2020). Common types of nursing diagnosis are risks, actual, and health promotion. This step is paramount in building a holistic perspective among the patients by the nurses. It facilitates safety and improves nurses' decision-making in their intervention’s implementation. An example of nursing diagnosis is risk of deficient fluid volume related to diarrhea, as evidenced by sunken eyes. 4 Planning Phase The step is fundamental for the nurses since an action plan is initiated. There is outcome identification as the health professionals set goals for the nursing care matching the nursing diagnosis (D’Agostino et al., 2018). The goals should be SMART, simple, measurable, achievable, realistic, and time bound. During the phase, the nurses ensure that reliable solutions are identified and planned on their attainment. Plan examples include improving the patient's nutrition by providing an adequate and well-balanced diet in small portions frequently for the next two days. Nurses use short-term goals or long-term goals to provide a reliable care plan. Implementation Phase As the nurse in practice, it is the duty to put the goals constructed at the planning phase into action. During implementation, nursing care is strategized based on the client's current condition and outcome. The care is put into action to lead to the client's optimal well-being. Patients' safety is prioritized during the implementation phase. Thus, shifts in patients' conditions should alter the step (Santana et al., 2020). Registered Nurses have the duty of ensuring that the interventions are relevant, ethical, and adhere to the Nursing Practice Act or federal regulations. An example of implementation is giving IV infusion of normal saline to a dehydrated patient. All the nursing activities are documented. Evaluation Phase This is the final phase in the nursing process and involves grading the outcomes of the implemented nursing interventions. Measurement of the success of the goals is determined based on the patient's current situation, and there are three possible outcomes to be evaluated (Movlavi et al., 2019). The patient's condition might be stabilized, improved, or deteriorated, determining the goal attainment. The patient is usually reviewed on the termination of the diagnosed 5 problems. The care plan constructed can be modified and revised to accommodate the replanning in the unmet goals. Evaluation is key to developing evidence for care delivery and involves reassessment. An example is whether the client understands the medication prescription for insulin injection. North American Nursing Diagnosis Association in Relation to Nursing Process The organization is tied to nursing practice which clarifies the terminology, systematic nomenclature, and taxonomy in the nursing diagnosis. It was created in 1982 and had 267 diagnoses for refinement and clinical use among nurses. NANDA is international and provides the nurses with a simplified and focused diagnosis (Ozkan et al., 2020). There are various domains within the NANDA and forty-seven classes. NANDA is therefore essential in the nursing process. There exist three major drawbacks in using NANDA among nurses; no statement for shifts in care priority, associated with neglect of nursing personalized interventions, and doesn't represent nurses' opinion in practice. Nursing Process and Critical Thinking Critical thinking is simply recognizing the patient's problem, analyzing the information, and evaluating the clinical issue. Nurses acquire the skill as they employ their nursing process within their practice. It is described as open-mindedness, continuous referencing, and determination of the patients’ response to improve their care (Falcó‐Pegueroles et al., 2021). Levels of critical thinking employed in the nursing process can be basic, complex, or commitment based on the nurses' qualifications and experience. Nurses utilize the skill to conduct a dependable assessment, construct an excellent judgment to state their nursing diagnosis, plan and evaluate their interventions. The health workers acquire brilliant decisionmaking abilities to offer the best nursing care. 6 Health Issue and its Application on Nursing Process A health issue example is my aunt, who is grieving the loss of her husband. The separation of the two partners has created a psychological and physiological disturbance to my aunt. As a nurse, it is fundamental to assist the client in recovering from the loss and assisting her in achieving her level of wellness by utilizing the nursing process with the five steps. Assessment During the initial phase, subjective data collected indicate the grieving process of the client who is confused, evidenced by her untidy grooming. The client complains of severe headaches and seizures, insomnia, and exhaustion. The objective data include hypertension and tachycardia for the patient. The client has psychological distress and lacks concentration. Diagnosis The client's diagnosis is drawn from the problem, etiology, and defining characteristic using NANDA. The diagnosis for the client is complicated grief related to loss of husband as evidenced by anxiety. Planning Various nursing interventions will be prioritized for the client to end her grief. The nurse should identify the loss with the client, acknowledge the unfortunate event, a short-term goal. Within two days, the client should be educated on the grieving stages, including denial, anger, bargaining, depression, and acceptance. The nurse must listen to the expressions of grief and put themselves on the same ground to console the client. The client should recover fully from the loss by improving their mental wellness. Assisting clients to resume regular activity is necessary and assisting them in adjusting within a month, long-term goal. 7 Implementation The nurse involves the client in engaging activities such as sports, interdependence. The client, dependent, can be given antidepressants as prescribed by the physician. The independent nurse provides counseling sessions to the client to discuss the loss and spiritual-related ideas to improve the clients' psychological health. The nurse provides the company with the client, consoles with her, and reveals the possible interventions to better her living without the husband. Evaluation The outcomes after the implementation are evaluated, and it is found that the client was able to regain her wellness. Most of the goals for the client were achieved, and psychological well-being is acquired; thus, this leads to termination of the care plan constructed utilizing the nursing process for the client. 8 Summary The nursing process is critical in the nursing process, and therefore, the professional should employ it to achieve quality nursing care. The process was constructed in 1960 and has five steps: assessment, nursing diagnosis, planning, implementation, and evaluation. NANDA provides a systematic international guideline on constructing the nursing diagnosis using the classes and domains. The nursing process contributes to the development of critical thinking skills, which are necessary for improving nursing care and overall wellness. A client case presented has utilized the nursing process and achieved wellness.