Nursing Knowledge Through Nursing Process

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Nursing Knowledge Through Nursing Process Jeremy, Gina, Krystal, Pearl, Renee NUR/403 January 25, 2015 University of Phoenix Belen Malayang The nursing process is a system of exploration, evaluation and planning aimed at delivering individualized patient care. The goal is to identify the existing or potential health needs of the patient and the best way of providing care to overcome problems and promote wellness. The nursing process has five steps, assessment, diagnosis, planning, implementation, and evaluation. Today we will discuss the nursing process and how it applies to John’s case study on page 379. We will further consider the nursing skills needed by the nurse (RN) and the scientific basis in each part of the nursing process. The assessment is the first step in the nursing process. The assessment phase is where information is gathered; this data will assist in forming diagnosis, outcomes and interventions. Analyzing a patient involves collecting both subjective and objective data. First, the RN needs to collect the data. Collecting data includes doing a thorough medical history along with listening to the client/family members and observing the client. Once the data is collected, it must be organized, validated, and then documented. In the case of John, the objective data is what the nurse observes, and data collected. This includes information such as John's shortness of breath per his nasal cannula and breathing treatments. Also, objective data can be obtained from previous documentation such as John's medical history including liver cirrhosis, emphysema, and mild anemia. The subjective data includes what John states during assessments. John responds to the question of how he is doing with "feeling better and ready for discharged". John also reports that he misses his daughter and wishes that someone in his life cared about him. John describes
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