The five phase nursing process is a cyclical process which allows nurses to recognise the patient’s nursing diagnosis in order to plot appropriate care. These phases involve assessment, diagnosis, planning, implementation and evaluation (ADPIE). The assessment phase forms the foundation for appropriate diagnosis, planning and intervention (Ackley & Ladwig, 2014 p. 3). Evaluation of nursing care allows for reassessments, restructuring of priorities and continuing review of care plan if the needs of the patient are not met (Davies and Janosik, 1991 p99; Brooker and Waugh, 2013 p304). Nurses need to be able to document a complete, systematic, and precise
Assessment The assessment portion of the nursing process is a way to gather as much information about the patient as possible. The assessment includes a physical examination and collecting the patient’s vital signs such as temperature, pulse, respiration, oxygen saturation levels, blood pressure, and pain level. The purpose of the assessment is to establish the patient’s baseline health levels so there will be a database to refer to. A patient interview is also included in the assessment portion of the nursing process. The interview will help the nurse gather information about the patient that may be helpful in a diagnosis.
Implementing EBP in nursing care establishes who they are, what they do, and what effect they have on patient outcomes (Overholt, 2004). All nurses have the responsibility to delivering the best care that will deliver the best outcomes to the patient. Evidence-based practice serves as a framework of how to prevent or treat common issues seen in clinical practice. The process of implementing EBP into clinical practice is accomplished by a series of steps or
The symptom is usually what brings the patient to seek out health care (Humphreys et al., 2008) and adherence to treatment by the patient is crucial. The nurse who provides a biopsychosocial view of the symptoms to help the patient better deal with their symptoms is imperative to this adherence. The Theory provides many target areas for research and furthers our knowledge of the development of symptom management. To provide a greater understanding
INTRODUCTION On admission to a healthcare facility, a health assessment is a mandatory tool in assessing the patient’s health status. In general an assessment is broken down into two types of reviews, by conducting a health history which includes the collection of subjective data (information elicited by the patient or patients’ family members) and a physical examination of the patient which includes the gathering of evidence based data (Wilson & Giddens, 2009). Collecting and documenting accurate information is imperative in providing the allied health team this information to facilitate an efficient and well-formed care plan in addition to establishing a baseline for subsequent assessments (Springhouse, 2004; Wilson & Giddens, 2009). PATIENT INTERVIEW A health assessment should consist of establishing a patient profile and incorporate a full medical history (Harvey, 2004). The traditional approach includes collecting subject matter on “biographical data, present health concerns (or present illness) and the chief complaint, past history, family history, review of system and patient data” (Farrell & Dempsey, 2010, p. 74).
The purpose of this paper is for the nurse to complete a health assessment of a family by using Gordon’s 11 functional health patterns and the system’s approach. By using open ended questions for the 11 principals, the nurse can predict potential problems in the health perception, nutrition, elimination, activity-exercise, cognitive perception, rest-sleep, self perception/concept, role relationship, sexuality, coping, values and beliefs by evaluating the risk taking and behavioral patterns within the family. A nursing diagnosis and care plan can then be developed by using the data collected during the interview. The nurse can then provide health care interventions which will assist the family in obtaining optimal health (Edelman & Mandle, 2010). The family interviewed consists of five family members.
Nursing practice can be best described as a person who is able to competently evaluate the patients conditions. They must be able to recognize not only verbal but non-verbal cues as well. Each patient is to be treated as an individual and on a case by case bases. The nurse must be qualified and have the compassion to properly analyze, assess, conduct a plan of care, and also provide intervention and evaluation. The nurse also has to treat the patient with dignity and aide in the healing process that is conducive to each individual.
History taking is a competent skill which enables practitioners to make accurate diagnosis and this skill is a fundamental requirement for the code of practice to maintain professional accountability (Nursing and Midwifery Council (NMC), 2010). Using a structured approach to guide the process can help the health professional to develop their skills in time management during the consultation and assessment. This ensures that the time a nurse has with the patient is used effectively and important elements are not missed (McEwen and Harris, 2010). Practitioners ‘must’ be apt in taking an accurate history from a set format ensuring that questions are pertinent to the diagnosis stated Crumbie (2006). In this case, the patient presented with a productive cough lasting over two.
The roles of nurses in each phase of the nursing process will be discussed. Skills and qualities of nurses in delivering quality care, evidence-based practice, multi-disciplinary team approach, and effective communication will also be considered in relation to nursing process. ASSESSMENT Assessment is the first step of the nursing process. It is defined by Carpenito-Moyet (2007) as an organised technique to collect information about a patient from different sources. In this phase, evidence of the problem and risks for problems are being examined.
The core concept of nursing is the diversity in healthcare settings dealt with the disparity between theorist of Florence Nothingale and Jean Watson. Florence Nothingale environment theory and metaparadigms will help establish the criteria which identify where and when nurse apply the core concept of nursing practice on a daily basis. Jean Watson theory is the philosophy and science of caring which is interrelated theories of Florence nightingale concepts. To understand these theory we have to understand the core concept of knowledge that will establish the path of explanations and give the meaning of a phenomena of nursing practice. These nursing practices must base on nursing theories we are using in the clinical setting of practice.