Making Nursing process

Okami_CCRN, BSN, RN · Jan 30, 2013

The nursing process is a topic that can easily be a series of lectures and in that respect this is just the tip of the iceberg. In American nursing schools we are taught to use the nursing process to create and implement a nursing plan of care. We begin with:

Assessment: in this phase of the nursing process we as practitioners collect data via objective (head-to-toe assessment) and subjective (pt. interview) avenues.

Diagnose: this is the second phase and we now use the data we collected in assessment to determine the problem. When formulating a nursing diagnosis it is important to remember that no medical jargon should be used. an example of a nursing diagnosis for a patient with pneumonia would be; impaired gas exchange related to (r/t) effects of alveolar-capillary membrane changes.

Planning: In the planning phase the patient and practitioner discuss attainable goals and outcomes. All outcomes must be followed with a date for achievement. Here you also discuss how you will manage the care of the patient. For example; Patient will attain SPO2 of 95% and above by January 31, 2013.

Implementation: In this phase you will put the plan that was decided upon between practitioner and patient to action. Let's continue with the patient with pneumonia, you will implement your nursing interventions; head of bed 30 degrees or higher, Chest PT Q6 hours, administer abx as ordered by physician, etc.

Evaluation: The final phase of the nursing process is one for reflection. Here we look back at whether the goals were met or partially met. This is also a time to change the nursing process. Let's suppose your patient with pneumonia did not achieve an SPO2 saturation of 95% or above by the date decided upon, you would document goal not met and why not. Maybe patient has COPD and an SPO2 of 90% is their norm.

I honestly hope this helps!