Nursing Process

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Introduction

·         The term Nursing Process was first used/ mentioned by Lydia Hall, a nursing theorist, in 1955 wherein she introduced 3 STEPs: observation, administration of care and validation.

·         Since then, nursing process continue to evolve: it used to be a 3-step process, then a 4-step process (APIE), then a 5-step (ADPIE), now a 6-step process (ADOPIE) Assessment, Diagnosis, Outcome, Identification, Planning, Implementaton and Evaluation.

Definition

·         Is a systematic, organized method of planning, and providing quality and individualized nursing care.

·         It is synonymous with the PROBLEM SOLVING APPROACH that directs the nurse and the client to determine the need for nursing care, to plan and implement the care and evaluate the result.

·         It is a G O S H approach (goal-oriented, organized, systematic and humanistic care) for efficient and effective provision of nursing care.            

·         Goal-oriented – nurse make her objective based on client’s health needs.

·         Remember: Goals and plan of care should be base according to clients problems/needs NOT according to your own problem as the nurse.

·         Organized/Systematic – the nursing process is composed of 6 sequential and interrelated steps and these 6 phases follow a logical sequence.

Humanistic care 

·         Plan to care is developed and implemented taking into consideration the unique needs of the individual client.

·         plan of care therefore is individualized (no 2 person has the same health needs even with same health condition/illness)

·         in providing care, it involves respect of human dignity

·         Efficient – plan of case is relevant/ related to the needs of the client thereby promoting client satisfaction and progress.

·         Effective – in planning care, utilized resources wisely (staff, time, money/cost)

Aside from GOSH, other characteristic of Nursing Process: 

·         Cyclic and Dynamic in nature – data from each phase provides the input into the next phase so that is becomes a sequence of events (cycle) that are constantly changing (dynamic) base on client’s health status.

·         Involves skill in Decision-making – nurse makes important decisions related to client care, she choose the best action/steps to meet a desired goal or to solve a problem. She must make decisions whenever several choices or options are available.

·         Uses Critical Thinking skills – the nurse may encounter new ideas or less-than-routine or non-ordinary situations where decisions must be made using critical thinking.

Purpose of Nursing Process: 

1.    To identify a client’s health status; his Actual/Present and potential/possible health problems or needs.

2.    To establish a plan of care to meet identified needs.

3.    To provide nursing interventions to meet those needs.

4.    To provide an individualized, holistic, effective and efficient nursing care.

Steps/Phases of the Nursing Process: 

1.    Assessment

2.    Diagnosis

3.    Outcome Identification

4.    Planning

5.    Implementation

6.    Evaluation

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