Question

Answer the following questions. Provide a cited rationale.

1. What are the steps of the nursing process?

2. Define each step, What happens during each step?

Answer 1

1. What are the steps of the nursing process?

There are five steps in nursing process and are as follows:

a) Assessment

b) Diagnosis

c) Planning

d) Implementation

e) Evaluation

2) a) Assessment

Assessment is defined as the systematic collection of patient data.

It involves collect data, validate data, organize data and document data.

1) Data collection( subjective and objective data)

• Nursing history:

i) Biographic data

ii) Current physical and emotional complaints

iii) Past medical history

iv) Past and current ability to perform ADL's

v) Socio economic factors

• Physical Assessment
• Review of lab and diagnostic test results.
• Review other available health informations.

2) Validation of data

The information gathered during the assessment phase must be complete, factual and accurate because the nursing interventions are based n this informations

3) Organization od data

The format may be organised according to the client's physical status.

4) Documenting data

Accurate documentation is necessary and should include all data collected about client's health status.

b) Diagnosis

Nursing diagnosis is a clinical judgement about individual, family or community responses to actual or potential health problems or life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

Each nursing diagnosis has three components:

i) Label an actual or potential health problems that nursing care can affect

ii) Related factors- factors that contribute with the human response

iii) Evidence - signs and symptoms that point to the diagnosis

Types of nursing diagnosis

i) Actual diagnosis : Statement about a health problem that the client has.

ii) Risk diagnosis : Statement about a health problem that the client does not have yet, but is at a higher than normal risk of developing in the near future.

c) Nursing Planning

Planning is defined as the process of thinking about the activities required to achieve a desired goal.

The third step of the nursing process, includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client's plan of care.

It has three phases:

i) Initial

ii) Ongoing

iii) Discharge

There are four critical elements of planning and are:

i) Establishing priorities

ii) Setting goals and developing expected outcomes.

iii) Developing expected outcomes

iv) Planning nursing interventions with collaboration and consultation as needed

d) Implementation

Implementation is defined as the step which involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care.

While implementing nursing orders, the nurse continues to reassess the client at every contact, gathering data about the client's responses to nursing activities and about any new problems that may develop.To implement the care plan successfully, the nurse needs:

i) Cognitive skills

ii) Interpersonal skills

iii) Technical skills

The implementation phase completes only by recording the interventions and the client responses in the nursing process notes.

e) Evaluation

Evaluation is defined as the judgement of the effectiveness of nursing care to meet client's goals.

Last phase of the plan of care, its the judgement of the effectiveness of nursing care to meet client's goals based on the client's behavioural responses.

When determining whether a goal has been achieved, the nurse can draw one of the three possible conclusions:

i) The goal was met - the client response is the same as the desired outcome

ii) The goal was partially met - Either a short term goal was achieved but the long term goal was not, the desired outcome was only partially met.

iii) The goal was not met.