Describe the nursing process and to develop nursing diagnosis based
The nursing process is the pillar in the delivery of quality health care services. It is considered as a tool that helps nurses to provide an integrated and holistic approach to patient care. According to the American Nurses Association (n.d.), nurses exercise a dynamic method of collecting data through the assessment of patient needs and conditions and then apply a clinical judgment in making a diagnosis to help them achieve a measurable and achievable short and long term goals of treatment. The implementation of the nursing process in clinical practice allows a nurse to deliver a patient centered care with the ability to provide individualized nursing services. It can help a nurse to assess, diagnose, plan, implement and evaluate treatment outcomes more accurately and methodologically that helps to focus on the unique and distinct health care needs of a patient. The implementation of the nursing process involves various phases and one of which is making a nursing diagnosis. This phase of the nursing process involves the ability of the nurse to exercise prudent clinical judgment regarding the patient’s current health condition. By using the nursing process as a tool in making a diagnosis, nurses will be able to diagnose using a more accurate method regarding the patient condition that will allow them to discover the collective sources of the patient’s chief complaint. For instance, during the assessment the patient may complain of pain. While pain is the chief complaint of the patient, the nursing process will help the nurse to identify the related causative factors such as the presence of depression, poor nutrition and poor immobility of the patient as contributing factors that may aggravate his pain. Using the collected data, a nurse becomes more competent in the exercise of a critical judgment in terms of diagnosing the patient’s condition that will help them in making a holistic approach in determining the appropriate nursing intervention and treatment for individual patient.
In general, the nursing process guides a nurse to collect relevant and important data that will be useful to the health care team in delivering a more patient centered nursing care.
In carrying out nursing diagnosis, a nurse usually manage both the subjective and objective data. The objective data is usually obtained by the nurse based on observation, evaluation and assessment of the patient while the subjective data is provided by the patient himself regarding how he feels and think about his condition (Ziegler, 2005). Both of these data are important in the conduct of nursing diagnosis to attain a holistic patient diagnosis and treatment plan. It is during the assessment phase of the nursing process that both the subjective and objective data are collected but they are translated into a more important component in the nursing diagnosis whereby a nurse responds to the information obtained during the assessment and then correlate them in order to make an accurate diagnosis about the patient condition. The chief source of information is basically the patient himself where subjective data is obtained according to the patient’s own perception of his condition and symptoms. Significantly, the patient can provide valuable information that cannot be obtained elsewhere such as the feeling of stress prior to the occurrence of his condition. He alone can tell whether he feels depressed, anxious, feels itching, fear and other qualifying symptoms that cannot be observed objectively by a nurse. Objective data on the other hand is acquired by the nurse based on medical records, physical assessment, environment health report, medication history, laboratory tests and other objective data. In making a diagnosis based on the objective data, the nurse should be able to obtain sources of information that are observable based on the signs and symptoms as well as the physical evaluation and laboratory data and other information that are obtained on record. The collection of both the subjective and objective data is crucial in the formulation of the appropriate and target nursing intervention plan, setting of treatment priorities, and determining expected outcome. Nursing process demands that important sources of information should be likewise obtained from other relevant sources like the patient, his family, primary care giver and medical records in order to determine the holistic approach that will address the patient’s physical, social, emotional, and spiritual needs (Lipe and Beasley, 2004). From the collected date a nurse can now critically assess the various aspects to consider in the patient’s condition. The nursing process is not mainly directly towards the disease process but rather aims to focus on the patient needs and problems. The subjective data for instance will show that the patient complains of pain and it is supported by an objective assessment of physical evaluation like palpation and range of motion but other factors also contribute to this perception of the patient which may be caused by the subjective feeling of depression and the fear of falling owing to his geriatric condition of frailty resulting to frequent immobility of the patient at home. By the intergration of the collected data from the subjective and objective sources help nurses to exercise an effective nursing diagnosis with a holistic approach that is centered in addressing the patient’s emotional, physical, psychological and spirtitual aspect for better patient recovery. Through an effective nursing process, nursing diagnosis can identify both the current and potential health problems including health risks that may affect the patient overall health and to help identify a holistic nursing intervention to address the patient’s general nursing needs.
American Nurses Association (n.d.). The Nursing Process. Retrieved from http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing/Tools-You-Need/Thenursingprocess.html
Lipe, S.K. and Beasley, S. (2004). Critical Thinking in Nursing: A Cognitive Skills Workbook. Philadelphia: Lippincotts, Williams and Wilkins.
Ziegler, S.M. (2005). Theory-Directed Nursing Practice. New York: Springer Publishing Company.