In: Nursing
Step 2 (Assessment) Look at your assessment data which is your subjective and objective data
Step 3 (Diagnosis) Develop your nursing diagnosis
Step 4 (Planning) you develop your patient goals this is the planning what you're going to do for this patient to help get them better and help them overcome this nursing diagnosis that you came up with
Step 5 (Interventions) these are nursing interventions this is what you're going to do in order to get the patient to meet their goals they're very patient-oriented and they're nurse specific
Step 6 (Rationale) This is where you will write out why you are choosing the interventions for your plan.
Step 7 (Evaluation) You're going to evaluate how the patient is meeting those goals and if not you're going to redo your maybe your diagnosis because the patient's changed or you're going to redo your nursing interventions
The nursing process is a series of organized steps designed for nurses to provide excellent care. The process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective.
The ABCs identifies the airway, breathing and cardiovascular status of the patient as the highest of all priorities in that sequential order.
Is the airway patent?
Rate, depth, pattern and sounds of breathing
Heart rate, BP, perfusion, beating of the heart (What is their EKG?
Maslow's Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others and the self-actualization needs in that order of priority.
Some physical needs include the need for the ABCs of airway, breathing and cardiovascular function, nutrition, sleep, fluids, hygiene and elimination.
The psychological or emotional, safety, and security needs include needs like low level stress and anxiety, emotional support, comfort, environmental and medical safety and emotional and physical security.
The love and belonging needs reflect the person's innate need for love, belonging and the acceptance of others including a group.
All people have a need to be recognized and respected as a valued person by themselves and by others. People have a need self-worth and self-esteem and they need the esteem of others.
Self-actualization needs motivate the person to reach their highest level of ability and potential.
Subjective data are information from the client's point of view (“symptoms”), including feelings, perceptions, and concerns obtained through interviews. Objective data are observable and measurable data (“signs”) obtained through observation, physical examination, and laboratory and diagnostic testing.
Examples of both subjective data (what the patient says) and objective data (what the nurse observes): A patient says she is shivering as the nurse observes her shaking in the chair.
A patient states he feels his blood pressure is high, which is subjective.
Nursing interventions are the actual treatments and actions that are performed to help the patient to reach the goals that are set for them. The nurse uses his or her knowledge, experience and critical-thinking skills to decide which interventions will help the patient the most.
Step 1: Data Collection or
Assessment
Step 2: Data Analysis and Organization
Step 3: Formulating Your Nursing Diagnoses
Step 4: Setting Priorities
Step 5: Establishing Client Goals and Desired Outcomes
Step 6: Selecting Nursing Interventions
Nursing interventions are informed by the results of nursing assessments. While the ultimate goal of an assessment is to decide on a course of treatment, an intervention in many cases is the treatment. Nursing interventions also go beyond simply “fixing” a patient medically. These actions can include:
Because nursing interventions describe nearly every interaction nurses have with patients, a thorough system is used to identify and evaluate their work.
The four types of nursing diagnosis are Actual (Problem-Focused), Risk, Health Promotion, and Syndrome.The NANDA-I system of nursing diagnosis provides for four categories and each has 3 parts: diagnostic label or the human response, related factors or the cause of the response, and defining characteristics found in the selected patient are the signs/symptoms present that are supporting the diagnosis.
The nursing process was initially an adapted form of problem-solving technique based on theory used by nurses every day to help patients improve their health and assist doctors in treating patients. Its primary aim is to know the health status and the problems of clients which may be actual or potential. It is made up of a series of stages that are used to achieve the objective—the health improvement of the patient. The use of nursing process can stop at any stage as deemed necessary or can be repeated as needed. This process is inclusive of physical health as well as the emotional aspects of patient health. Nursing knowledge is used throughout the process to formulate changes in approach to the patient’s changing condition.
Many nurse researchers and theorists are in agreement that nursing process is a scientific method for delivering holistic and quality nursing care. Therefore, its effective implementation is critical for improved quality of nursing care. When the quality of nursing care is improved, visibility of nurses’ contribution to patient’s health outcomes becomes distinct. In this way, nurses can justify the claim that nursing is a science and an independent profession Nurses are the largest group of health professionals in all countries. Nursing care quality is closely related to a health care system’s effectiveness. In order to achieve the quality of health care service, quality of nursing care is the key element and to fill this demand application of the nursing process has a significant role, but, in practice, application of the nursing process is not well developed