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Throughout your nursing career, you will be using the nursing process.
This module will guide you in understanding the nursing process steps
of assessment, analysis, planning, implementation, and evaluation.
You are responsible for:
1.
Studying the content of this module.
2.
Completing the practice exercises.
3.
Writing a care plan.
Objectives:
1.
Describe the relation between critical thinking and the nursing
process
2.
Identify and explain the components of the nursing process
3.
Discuss the major activities of the assessment phase
4.
Identify the activities of the nursing diagnosis
5.
Discuss the planning phase
6.
Discuss the activities of the implementation phase
7.
Describe the component of the evaluation phase
INTRODUCTION
This is a brief overview of the nursing process. In the topic of
pharmacology, nurses dont just give meds. They employ the nursing
process to assess the patient in order to determine if the patient
should have the medication, analyze the gathered data and make a
nursing diagnosis, plan a goal and actions, implement those actions to
reach the goal, and evaluate the results.
1.
Describe the relation between critical thinking and the
nursing process
What is critical thinking and why does it matter?
The nursing role requires an organized, purposeful, and disciplined
thinking process. We apply this thinking process in several ways:
Nurses are required to solve patient problems by critically
analyzing the factors associated with these problems. This
critical analysis allows the nurse to make better decisions.
Creativity is necessary to solve these problems.
Nurses dont just problem solve and make decisions, they make
observations, draw conclusions, create new ideas, evaluate, and
modify; to do this, critical thinking is employed.
Nurses may do things with little or no critical thinking from small
decisions to repetitive psychomotor skills. Higher-level critical thinking
comes into play, however, when the nurse must make a less-thanroutine decision. This is often called problem solving.
2.
Identify and explain the components of the nursing
process
A process is a series of planned actions or operations directed toward a
particular result or goal. It is a problem-solving procedure.
The nursing process is a systematic method of planning and providing
nursing care. It is a decision-making approach that promotes critical
thinking. The major purpose of the nursing process is to provide a
framework within which the needs of the patient can be met.
The nursing process consists of five steps or phases:
Assessing, Diagnosing, Planning, Implementing, and Evaluating.
Briefly stated, the steps are:
Assessing To gather information, organize it, validate it, and
document it.
Diagnosing To analyze data, identify the health problems, risks
and strengths, and formulate diagnostic statements.
Planning To determine the priorities of care and formulate
expected goals/outcomes, select nursing interventions, and write
nursing orders.
Implementation To complete the nursing actions necessary to
accomplish the goals, reassess the patient, determine the need
for assistance, delegation and supervision, and document the
nursing actions.
Evaluation To collect data about goals/outcomes, compare with
the planned goals/outcomes, determine the extent to which the
goals were accomplished; continue, modify, or terminate the
plan.
The nursing process is an adaptation of problem-solving techniques. It
can be viewed as parallel to yet separate from the medical process.
The medical process focuses on the disease and the nursing process is
directed toward the patients response to the disease or illness.
3.
Discuss the major activities of the assessment phase
The assessment phase is where information is gathered regarding the
patient for the purpose of identifying the patients needs, concerns,
problems, or human responses. It involves data collection,
organization, and validation.
Assessing is a continuous process carried out during all phases of the
nursing process. All phases of the nursing process depend on the
accurate and complete collection of data.
2.
a.
b.
c.
d.
Inspecting.
Auscultating.
Palpating.
Percussing.
In
a.
b.
c.
d.
e.
3.
a.
b.
c.
d.
2.
is:
a.
Risk for
b.
Risk for
c.
Risk for
eyesight.
d.
Risk for
eyesight AEB
falling.
5.
injury.
injury R/T stroke.
injury R/T weakness on right side, decreased
injury R/T weakness on right side, decreased
Once the assessment data have been collected, analyzed, and the
nursing diagnosis has been identified, the nurse moves on to the
planning phase of the nursing process.
The nurse refers to the assessment findings and diagnostic statements
for direction in formulating patient goals and designing the nursing
strategies required to treat the patients health problems.
The nurse sets a goal (or outcome) for each nursing diagnosis. The
goal is a desired outcome or change in patient behavior. It should be
specific, measurable, and include a time frame for attainment. When
the goal is achieved, the patients problem described in the nursing
diagnosis is solved.
Components of the Goal
1. Subject
2. General behavior that is desired
3. Time frame
4. Specific indicators (evidence)
Subject: The goal is patient-directed. Begin the goal statement
with Patient will
General behavior: The behavior that is desired is a REVERSAL of
the problem as seen in the nursing diagnosis.
Restate the NANDA portion of the nursing diagnosis in a positive
manner:
3.
6.
The nurse has written the goal, Patient will have decreased pain
with 8 hours AEB patient reports pain at 2 on pain scale of 1-10.
An appropriate implementation would be:
a.
Assess breath sounds every 2 hours.
b.
Place in position of comfort.
c.
Instruct how to deep breathe.
d.
Administer insulin according to sliding scale.
2.
a.
A goal of Patient will have decreased pain.
b.
A nursing diagnosis of Impaired tissue integrity.
c.
A goal of Patient will have improved airway clearance
within 8 hours
AEB productive cough.
d.
A nursing diagnosis of Ineffective airway clearance R/T
pneumonia.
7.
Lippincott Manual of Nursing practice 8th edition. Lippincott Williams and Wilkins
(2006).
Prepared by: Asst. Professor 1 Jennifer Tan-Mansing RN; MAN