The Nursing Process: Risk For Injury Paper

The Nursing Process: Risk For Injury Paper

Nursing is a profession which is prominent across the world. When society changes, nursing also changes. Nurses possess a skill unlike other professionals; nurses must master more information than ever before

available about human health and disease. Not only do nurses have to be intelligent but they also must be good leaders and team members, as well. Nurses must learn to think in a variety of different ways. Critical and creative thinking is often necessary and communication skills must be optimal. A successful nurse must also grapple with practical, ethical, and legal dilemmas. All of the above qualities make what it takes to be a reputable nurse, who can execute the nursing process effectively (Chitty 1).

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Nursing is “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA 7). The science of nursing is based on a critical thinking framework, known as the nursing process.The Nursing Process: Risk For Injury Paper

The nursing process is composed of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. These steps serve as the foundation of clinical decision making and are used to provide practice for patients. Nurses are always using critical thinking to respond to the needs of clients, and use strategies that support a promising outcome most appropriate for the patient’s situation (Wilkinson 1-3).

Recently, some nursing leaders have been questioning the effectiveness of the nursing process. These subjects argue that by using the nursing process system, nurses are merely writing a textbook diagnosis rather than successfully looking at the patient’s case. Most agree, however, that the nursing process is important because the nursing process benefits the clients by focusing on them. The nursing process promotes collaboration between the health team by delivering effective, individualized care, and the work atmosphere becomes more positive. The nursing process also prevents errors and speeds up diagnosis, treatment, and prevention of patient problems; this means that the client will spend less time in a hospital and therefore lowers cost. The nursing process also makes it easier to understand what nurses do and individualizes care for the patient that the doctor can not provide in a few simple steps (Wilkinson 7-9)

The first step of the nursing process is the assessment phase: getting the facts. In this first stage, the nurse collects, organizes, validates and records data about the patient’s current health status. The data is collected in a systematic and ongoing process. Data is obtained through examination of the patient, talking to the client and their family, and reading charts and records. While examining the patient, appropriate evidence based assessment techniques and instruments are used. No conclusions are drawn from this first stage (Wilinson 14). The nurse then prioritizes data collection based on the patient’s immediate needs, or anticipated needs of the patient or situation. The registered nurse synthesizes the available data, information and knowledge relevant to the situation to identify patterns and variances. The nurse documents everything in this first stage (ANA 21). Data may possibly include physiological, psychological, sociology-cultural, developmental, spiritual, or environmental information. In this initial phase, the patient’s available financial or material resources also need to be assessed and recorded.The Nursing Process: Risk For Injury Paper

Within this first step of the nursing process, there are two separate types of data: subjective data and objective data. Subjective data are gathered from patients as they express their needs, feelings, strengths, and perceptions of the problem. This data can often be referred to as symptoms. The only source for this data is the patient. Subjective data includes physical, psycho social, and spiritual information. The other type of information is objective data. These are the data that the nurse obtains through observation, examination, or discussion with other health providers (Chitty 394-395).

The patient’s data can be obtained through many sources during the assessment phase of the nursing process. The patient is considered the primary source. Sources of data that the nurse observes or reports of family and friends of the patient are considered secondary sources. Tertiary sources include medical records and information gathered from other health providers (Potter-Perry 279-285).

The second phase of the nursing process is the diagnosis stage. In this stage, the nurse sorts, clusters and analyzes data in order to identify the patient’s current health status. The nurse also writes a description of the patient’s status and the factors that are contributing to it. The nurse prioritizes the nursing diagnoses and finally decides which diagnosis will respond to nursing care and which need another professional (Quan).

NANDA, the North American Nursing Diagnosis Association, provides a standardized set of labels for nurses to use in writing nursing diagnoses. This organization is the leader in nursing diagnoses classification. VANDA-approved nursing diagnoses consist of five components: label, definition, defining characteristics, risk factors, and related factors.The Nursing Process: Risk For Injury Paper The first component, label, is a concise term or phrase used to name the diagnosis. The second part, definition, clearly explains the meaning and helps to set apart from alike diagnoses. The third piece, defining characteristics, contains bunched of observable inferences. The fourth aspect, risk factors, is the factors that increase danger to the patient, which could lead to an unhealthful event. The final factor, related factors, is features that are associated with the diagnosis (Chitty 397)

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The third standard of the nursing process is planning outcomes. Planning begins with the identification of the patient’s goals. The goals that are decided upon help the patient and nurse to guide the selection of interventions and to evaluate patient progress. While determining the desired outcome, a period of time for the change to occur is also decided on. The nurse also must consider the patient’s risks, benefits, costs, current evidence, and clinical expertise when formulating expected outcomes. The nurse also documents the expected outcomes as measurable goals (ANA 25).

This third stage is much more complicated than it appears at the surface. Outcome criteria must be decided on, which is what d defines the terms under which the goal is said to be met, partially met or unmet. Also, there are several types of patient goals. A goal that requires motor skills is a psycho motor goal. A cognitive goal deals with a desired change in a patient’s knowledge level. Effective goals involve a change in mood, values, beliefs or attitudes. All goals are established along with a time period. Short-term goals may be attainable in hours or days; whereas, long-term goals usually represent a major change that could take months or even years (Chitty 400).

The fourth stage, planning interventions, is when the registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. The plan is sensitive to the patient’s characteristics and the situation. The Nursing Process: Risk For Injury Paper The nurse includes strategies within the plan that address each of the identified diagnoses or issues, which may involve strategies for promotion and restoration of health and prevention of illness, injury and disease. The plan incorporates the timeline previously decided on and the nurse establishes the plan’s priorities with the patient, family and others as appropriate. The nurse always must consider the economic impact of the plan on the patient, and when everything is established, the nurse must document the plan in the medical files. The end product of this phase is almost always a written plan of care; however, in some cases, planning is simply the mental process of choosing what to do. Acting without a written plan is acceptable; acting without a plan is not (Wilkinson 15).

The fifth stage of the nursing process is implementation. In this phase, the nurse communicates the plan of care to other members of the healthcare team and carry out the interventions indicated on the plan or delegate them to others. While the nurse is doing this, the nurse is sure to do so in a safe and timely manner. The nurse also documents any modifications, including changes or omissions, of the identified plan. The nurse must also do his/her best to utilize community resources and systems to execute the plan. The final activity of this phase is to record the care given and the client’s responsiveness (ANA 26).

In this phase, interventions vary widely, depending on the nursing diagnosis and the patient goals. As the nurse is carrying out the intervention, he/she is continually assessing the patient, noting responses to interventions and modifying the care plan as needed.The Nursing Process: Risk For Injury Paper

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The final stage of the nursing process is the evaluative stage. This phase includes the nurse’s examination of the patient’s progress in relation to the goals and stated outcome criteria to determine whether a problem has been resolved, is in the process of being resolved, or is unresolved. During the evaluation, the nurse conducts a systematic, ongoing, and criterion-based evaluation of the outcomes in relation to the structures and processes prescribed by the plan and the indicated timeline. The evaluation stage may reveal the data, diagnosis, goals, and nursing interventions were all on target and that the problem is resolved, or it may also reveal the need for a new diagnosis and plan (Chitty 403-404).

The nursing process is not so easily separated into steps when it is being practiced in a place of medical care, but all the steps are always used and effective if used properly. The process is often necessary in delivering care to both well and ill clients by identifying the patient’s current health status and focusing on desired outcomes. The nursing process is a developed, reliable and easy-to-work-with system that will continue to last for decades. The Nursing Process: Risk For Injury Paper

 

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