Application of the Nursing Process (Term Paper Sample)

Application of the Nursing Process
Student’s Name
Institutional Affiliation
Introduction
Nursing process refers to the system of assessment, evaluation and planning whose goals is to deliver personalized patient care irrespective of whether it is done to a single person, family or an entire community. It aims at identifying existing gaps in provision of health services to clients in order to overcome health issues. When the information has been collected and evaluated, a decision is then arrived at depending on the need of a given situation. The nursing process is composed of five steps namely; assessment, diagnosis, planning, implementing, and evaluating (Doenges & Moorhouse, 2012).
Part 1: The Meaning and the Use of the Nursing Process
Assessment
This is the first phase in the nursing procedure which involves "collection of data, verification, organization, as well as interpretation and documentation of the collected data (Perry, Potter & Ostendorf, 2015)." The accuracy and completeness of the information taken during this process are directly connected to the correctness of the steps that follow.
Data is obtained from different sources; however the client should considered as the basic source of the data. Other providers of information of the data like family members and friends are considered as secondary sources. Assessment stage offer significant information that creates the client database. There are two types of information collected; subjective ad objective information. Subjective information indicatesthe client’s point of view and includes feelings, concerns and perceptions. On the other hand, objective information details the observable as well as measurable data which are obtained through standard assessment methods done during the client’s physical examination (Doenges & Moorhouse, 2012). For instance, body temperature. Validation is a significant step in this assessment stage because it ensures that data collected is accurate and that there are no any omissions. It also prevents misunderstandings as well as preventing wrong inferences and conclusions.
Diagnosis
This is the second process in nursing and is concerned with further analysis and synthesis after assessment has been done. Analysis involves the overall breakdown into sections that can be examined while as synthesis is concerned with allocation of data together in a new method. (NANDA)The American Nursing Diagnosis Association defines nursing diagnosis as the clinical judgment about a person, family or society responses to real or potential health issues. Nursing diagnoses offer the foundation on which the selection of interventions is formulated. It is through this step that the rest of the nursing process of the basis for a patient care is delivered.
There are two categories of diagnosis; medical and nursing diagnosis. The former focuses on the illness, injury and disease process while as the later focuses on the response to real or potential implications on health or life process of the client. In establishing nursing diagnosis, a nurse applies both critical thinking as well a decision making skills (Doenges & Moorhouse, 2012). To achieve this, nurses use such questions as; are there problems here? What are the possible reasons for the problem? What are the risk factors? And what data is available to answer the question?
The following are the main types of nursing diagnosis:
Actual diagnosis: this shows that an issue exists and comprise of diagnostic label, related factors as well as signs and symptoms. A good example is theimpaired skin integrity which is related to prolonged pressure prominence.
Risk nursing diagnosis: This type of diagnosis shows that there is potential problem though it has not yet presented itself. For instance, risk for impaired skin integrity that is related to difficulty of an individual turning side by side.
Possible diagnosis: It shows that if appropriate preventive measures are not taken, then a problem will occur.
Wellness nursing diagnosis: It shows the patients desire to attain a certain level of wellness in particular area of function (Doenges & Moorhouse, 2012).
Planning
This is the third step of the nursing process. It comprises of the formulation of procedures that develop the proposed outline of nursing activities in the resolution of nursing diagnosis as well as the establishment of a patient’s plan of care. Planning begins after nursing diagnosis has been established a client strengths have been determined. The planning process involves the following four tasks:
Prioritization of nursing diagnosis list
Identification of client centered long and short term goals and results
Development of specific interventions
Recording of the overall plan of care in the client’s record.
Implementation
This is the fourth stage in nursing process. It entails the execution of the nursing plan of care composed during the planning stage. In addition, it consists of nursing activities which have been planned to meet the objectives set with the client. This stage involves several skills and the nurse should keep on assessing the patient’s condition before, during and even after the nursing intervention.Reporting and documentation are another significant activities performed at implementation stage (Doenges & Moorhouse, 2012). The information to be reported and documented includes; condition before intervention, the particular intervention carried out, patient response to the intervention, and finally the client outcomes.
Evaluation
This is the final stage in nursing process. It is entails determining if the patient’s goals have been attained, partially attained or not attained. If the goals have been met, the nurse should determine whether nursing activities will stop or continue so as to maintain status. If the goals have been partially attained or totally not attained, the nurse should reassess the situation. Evaluation is usually an ongoing activity.
Nursing Interventions
Nursing intervention refers to a treatment carried out upon clinical judgment, skills and knowledge by a nurse in order to enhance a patient outcome (Doenges & Moorhouse, 2012). In the implementation stage, there are two types of intervention care namely; direct and indirect interventions care. Direct nursing intervention care is treatment that is carried out by engaging the client. On the other hand, indirect nursing intervention is the kind of treatment that is carried out away from the client although on behalf of the client.
Types of Nursing Interventions
Nurse initiated interventions: They are those treatments that the nurse is capable of initiating independently. For example, a nurse educating a patient on the purpose of medication, its side effects and the possible consequences of a disease if he does not take the medication
.Dependent intervention: These are interventions that need an order from another health care provider like a physician. For example, a nurse report a condition he cannot handle to a physician who orders an antihypertensive medication for the client. The nurse will then administer the medication as required by the physician.
Interdependent interventions: They demand participation of several members of health care team. For example, apart from the order by physician above, the patient suffering from high blood pressure may reveal that he consumes diet which is high in sodium. The nurse may include diet counseling in the patient care plan. These interventions by different health care professionals constitute interdependent intervention (Doenges & Moorhouse, 2012).
Nursing process provides the foundation on which registered nurses can make informed judgment in that is a complex process that its application and mastering require creativity after which the nurse gains relevant skills in nursing. The steps remain the same although the application and outcomes may be different in every client situation. It is also a fundamental organizing system for the National Council Licensure Examination for Registered Nurses (NCLERN). If the outcomes are not achieved, the nurse has to reassess the situation by collecting data to determine the reason for not attaining the goals and the necessary modification of plan of care different from the previous one that did not yield results.Critical thinking enables a nurse to make decisions on priority of care. He can determine which diagnosis requires attention before any other. Life threatening situations are usually given the first priority although there are other several frameworks that can be used to prioritize plan of care (Jefford et al., 2013).
Part 2: Development of a Plan of Care
Nursing Care Plan
Assessment
As earlier noted, this stage will involve collection of data, organization and interpretation of data.
The physician is a 78 year old man living in assisted care living facility.
He can walk for short distances and a wheelchair for a bit longer distances. He can administer his own medications and bathes himself as well.
For the last one year, he opts to sit on his wheel chair even when in his room.
His previous conditions; CHF, hypertension, hyperlipidemia, and lower extremity weakness.
Current medications include; 50 mg of (lepressor) once daily orally administered, furosemide (Lasix) 20 mg once daily orally administered, Quinapril (Acupril) 20 mg once daily orally administered, atorvastatin (Lipitor) 20 mg orally administered.
Diagnosis
Actual diagnosis: Pressure ulcer over the ischium on the right buttocks. The wound is oval about 10mm x 8mm and has red and yellow patches in the middle and black areas surrounding tissue. The wound also has a bad odor. This is related to prolonged pressure on bony prominence due to his previous lowe...