For the Purpose of this assignment I will change the name of the patient and will keep the name and location of the Hospital confidential to in keep with the NMC’s code of professional conduct (2004).
The Nursing Process is a systematic approach to planning and delivering nursing care. It is a 5 stage process that includes assessment, diagnosis, planning, implementing and evaluating care. Each stage is dependent on the other in a cyclical process. The Nursing Process works in conjunction with a nursing model, models of nursing are used to provide frameworks of care. (Holland et al, 2008)
Holistic assessment of the patient identifies all of the patients individual needs in order to identify their problems, needs may be actual or potential. (Holland et al, 2008)
Collecting data using objective and subjective information, objective data is observations or measurements made by the collector for example blood pressure. Subjective data is obtained from the patient, family and significant others or health records. (Holland et al, 2008)
This is a nursing diagnosis as opposed to a medical one. This needs to be achieved so that appropriate care can be planned. Problems maybe actual or potential. (Holland et al, 2008)
Through planning there is a need to state goals or find desired outcomes for each problem/need. Goals need to be measurable, attainable, client centred, realistic, outcome written and short. When planning care evidence based research should be used to support the planning process. (Holland et al, 2008)
Implementation is the carrying out of the nursing interventions using theoretical and experiential knowledge, skills and clinical expertise based on evidence based practice. (Holland et al, 2008)
When evaluating the care given a number of questions must be considered. Was appropriate data collected?, Were appropriate problems identified from that data?, Have the Goals been achieved?, Was the care effective?, Has the care been...