The Nursing Process and Diagnosis Based on Patient Data
First defined by Ida Jean Orlando, the nursing process is a series of steps that nurses use in delivering quality care . The framework directs their activities in protecting and promoting the health of individuals, families, and communities. Additionally, nurses can identify various illnesses and prevent risk factors using this process. Most importantly, they collect objective and subjective data with the aim of coming up with a comprehensive history that might have led to a given ailment. Then, they follow the steps of the nursing process for appropriate intervention and its evaluation. They include assessment, diagnosis, planning, implementation, and evaluation. The paper analyzes the nursing process and explains how to develop a nursing diagnosis based on objective and subjective data.
The first step of the nursing process is assessment. In this part, nurses collect necessary information on the psychological, physiological, spiritual, and sociological state of the patient. Such data are collected in various forms. For instance, a nurse can conduct an interview with the patient, asking the one about his or her health status, when the illness began, how the person has been coping with the disease and any measures he or she has taken in addressing it. Additionally, nurses inquire about the family history and conduct general physical examinations. Significantly, they have to interact with the patient in a nonjudgmental manner and create a rapport to make sure that the client gives correct information.
The diagnosis phase of the nursing process was added later to the original steps offered by Ida Jean Orlando. During it, nurses judge an actual and potential health problem of the individual, family, or the community. Since they spend a considerable amount of time collecting data, multiple diagnoses in a single patient are possible. In this regard, a nurse needs to employ critical thinking, proper social skills and have comprehensive knowledge of data assessment to make an appropriate diagnosis. This phase is critical because it is used to determine the medical regimen and nursing interventions for the patient.
After obtaining patients data and making an appropriate diagnosis, it is paramount to plan intervention because all problems cannot be dealt with at once. Therefore, the nurse prioritizes patient issues and devotes attention to severe conditions and high-risk factors. Then, the one sets clear goals for each problem, being particular with the timeframe for the achievement of any given goal. Conditions that do not involve many risks are also involved in a plan with the time indicated for the attainment of set objectives. Most importantly, nurses refer to the Nursing Interventions Classification (NIC) that has research-based information. The utilization of the latter is significant because it enables health professionals to deliver care based on the evidence available, but not on opinions or personal judgments.
At this stage, nurses intervene appropriately pursuant to plans laid down previously. Most importantly, they focus first on tasks of top priority since they involve many risks. For instance, in a patient who presents with a difficulty in breathing and other symptoms in the emergency department, nurses must use an open airway first because it is a priority intervention. For a person put on medication, healthcare professionals monitor his or her health to ascertain whether the one is improving or deteriorating. Additionally, nurses educate clients, perform various medical tasks, and refer persons where necessary. This phase can last for a few hours, days, weeks, or even months. After intervening appropriately, nurses proceed to the evaluation stage.
This stage is the last one in the nursing process. After assessing, diagnosing, planning and administering intervention to a patient, family or a community, nurses evaluate their actions in a given time to determine the effectiveness of the plan. If the latter did not work well, nurses should identify the problem to begin the whole process afresh. Significantly, the nursing process is dynamic in nature. It is not rigid because the patient's condition changes over time.
To come up with an adequate diagnosis, nurses must obtain both objective and subjective data from patients. The latter involve such information from clients as feelings, pain, hunger, and beliefs. Nurses collect these data using an interview because such can only be confirmed when the patient verbalizes. Using this information, nurses document data, based on which they can draw a nursing diagnosis, for instance, pain related to a given condition. On the other hand, objective data come from what a nurse can observe and measure. The method of data collection employed here is a physical examination to review body systems. From these data, nurses can come up with such information as hyperthermia related to a given condition as evidenced by the measured high temperature of the client.
The nursing process is critical in the management of patients. Nurses use this framework in collecting subjective and objective data with the aim of coming up with appropriate diagnoses. Then, they plan interventions and implement the plan to achieve the set patient-focused goals. If the process is ineffective, the nurse will have to repeat it because it is dynamic. Considerably, such healthcare professionals must embrace the nursing process and utilize evidence-based practice to deliver quality care.
If the article was cognitive for you, proceed to read other articles on https://top-papers.com/ company. Most of the articles are written by Patricia Lambert, a professional writer.