The Process Of Becoming A Nurse – In 1958, Ida Jean Orlando began developing the nursing process that is still evident in nursing. According to Orlando’s theory, the patient’s behavior sets the care process in motion. Using nursing expertise to analyze and diagnose behavior to determine patient needs.
Using fundamental principles of critical thinking, client-centered approaches to treatment, goal-directed tasks, evidence-based practice (EBP) recommendations, and nursing intuition, the nursing process serves as a systematic guide to client-centered care with five steps to follow. These are assessment, diagnosis, planning, implementation and evaluation (ADPIE).
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The nursing process is defined as a systematic, rational planning method that guides all nursing activities in providing holistic and patient-centered care. The nursing process is a form of scientific reasoning and requires the critical thinking of the nurse to provide the best possible care to the client.
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The nursing process consists of five stages: assessment, diagnosis, planning, implementation and evaluation. The acronym ADPIE is a simple way to remember the elements of the care process. Nurses must learn to implement the procedure step by step. However, as critical thinking develops through experience, they learn to move back and forth between the stages of the caregiving process.
The stages of the nursing process are not separate entities, but rather overlapping, continuous subprocesses. In addition to understanding nursing diagnoses and their definitions, the nurse promotes an understanding of the characteristics and behaviors defined by the diagnoses, factors associated with selected nursing diagnoses, and appropriate interventions to address the diagnoses.
The first step in the nursing process is assessment. This includes collecting, organizing, validating and documenting clients’ health status. This data can be obtained in several ways. In general, when a nurse first meets a patient, the nurse must perform an assessment to identify the patient’s health problems, as well as the physical, psychological, and emotional state, and create a database of the client’s response to the problems health or illness and abilities. . to manage health care needs. Critical thinking skills are essential to assessment, so concept-based curriculum changes are needed.
Data collection is the process of gathering information about the client’s health status. The data collection process must be systematic and continuous to avoid missing important customer information.
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The best way to collect data is through a top-to-toe assessment. Find out more in our guide: Head to Toe Assessment: The Complete Guide to Physical Assessment
Data collected about a customer is usually categorized as objective or subjective, but the data can also be verbal or non-verbal.
Objective data are visible, measurable, tangible data collected through the senses, such as sight, touch, smell, or hearing, and compared to accepted standards, such as vital signs, intake and output, height and weight, body temperature, pulse and respiratory rate, blood pressure, vomiting, abdominal distention, edema, lung sounds, crying, skin color, and sweating.
Subjective data includes hidden information such as feelings, perceptions, thoughts, feelings or concerns shared by the patient and can only be verified by the patient, such as nausea, pain, numbness, itching, attitudes, beliefs, values and perceptions. for health problems and life events.
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Oral data is oral or written data, such as statements from a customer or secondary source. Verbal data requires the nurse’s listening skills to assess difficulties such as confusion, tone of voice, assertiveness, anxiety, difficulty finding the right word, and flight of ideas.
Nonverbal cues are observable behaviors that convey a message without words, such as the patient’s body language, general appearance, facial expressions, gestures, eye contact, proxemic (distance), body language, touch, posture, clothing. The non-verbal data received can sometimes be more powerful than the verbal data because the client’s body language may not correspond to what they are actually thinking or feeling. Collecting and analyzing nonverbal data can help augment other types of data and help understand what the patient is really feeling.
Data sources can be primary, secondary and tertiary. The client is the primary source of data, while family members, support persons, records and reports, other health professionals, laboratory and diagnostics are secondary sources.
The customer is the only primary data source and the only one that can provide subjective data. Everything the client says or reports to members of the health care team is considered primary.
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A source is considered secondary data if it is provided by someone other than the client, but within the context of the client’s report. Information provided by the client’s family or significant others are considered secondary data sources if the client cannot speak for himself, lacks evidence and understanding, or is a child. In addition, client records and assessment data from other nurses or other members of the health care team are considered secondary data sources.
Sources outside the customer’s reporting system are considered tertiary data sources. Examples of higher education data include information from textbooks, medical and nursing journals, medication manuals, surveys, and policy and procedure manuals.
The most common approach to gathering important information is the interview. An interview is an intended communication or conversation with the purpose of, for example, obtaining or providing information, identifying mutually important issues, evaluating change, teaching, providing support, or providing advice or therapy. An example of an interview is the nursing health history that is part of the nurse admissions assessment. Interaction with the patient is usually the most difficult part of the assessment stage of the nursing process, so rapport must be established at this stage.
In addition to conducting interviews, nurses will perform physical examinations that refer to the patient’s health history, take the patient’s family history, and may also use general observations to gather assessment data. Establishing a good physical assessment would later lead to more accurate diagnosis, planning and better intervention and evaluation.
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Observation is an assessment tool that relies on using the five senses (sight, touch, hearing, smell, and taste) to learn information about the client. This information relates to the client’s appearance, performance, primary relationships, and environment. Although nurses observe primarily through vision, most of the senses are involved during close observation, such as smelling unpleasant odors, hearing or hearing lung and heart sounds, and feeling pulse and other palpable skin abnormalities.
Validation is the process of checking data to make sure it is accurate and true. One way to confirm observations is to ‘double check’ and allows the nurse to:
Once all the information is collected, the data can be recorded and organized. Excellent record keeping is essential so that all data collected is documented and explained in a way that is available to the entire healthcare team and can be referenced during assessment.
The second stage of the nursing process is the nursing diagnosis. The nurse will analyze all the information collected and diagnose the client’s condition and needs. Diagnosis involves analyzing data, identifying health problems, risks and strengths, and making diagnostic statements about a patient’s potential or actual health problem. Sometimes more than one diagnosis is given to the same patient. Forming a nursing diagnosis through clinical assessment helps plan and implement patient care.
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Nursing diagnosis types, elements, procedures, examples, and writing are covered in more detail here, The Guide to Nursing Diagnosis: Everything You Need to Know to Learn Diagnosis
Planning is the third step in the care process. Provides guidance for nursing interventions. Once the nurse, any supervising medical staff, and the patient agree on a diagnosis, the nurse plans a course of treatment with short-term and long-term goals in mind. Each problem has a clear, measurable goal to achieve the expected beneficial outcome.
The planning phase formulates goals and outcomes that directly affect patient care based on evidence-based practice (EBP) guidelines. These patient-specific goals and their achievement help ensure a positive outcome. Nursing care plans are essential in this goal setting phase. Care plans provide direction for personalized care tailored to an individual’s unique needs. General condition and comorbidities play a role in developing the care plan. Care plans improve communication, documentation, reimbursement, and continuity of care across the health care continuum.
Planning begins with the first contact with the client and continues until the end of the nurse-client relationship, preferably when the client is discharged from the health care facility.
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Initial planning is done by the nurse who conducts the admission assessment. It is usually the same nurse who creates the initial integrated care plan.
Ongoing planning is done by all nurses working with the client. As the nurse receives new information and assesses the client’s responses to care, she can continue to individualize the initial plan of care. A continuing care plan is also displayed at the start of the shift. Continuous planning allows the nurse to:
Discharge planning is the process of anticipating and planning for post-discharge needs. To ensure continuity of care, nurses must:
A Nursing Care Plan (NCP) is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans provide communication between nurses, their patients, and other health care providers
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