This article is written with the objective being to inform the lay reader about the nursing process that takes place within health care institutions in the USA. while under the care of a registered nurse during a hospitalization.
The steps in the nursing process includes: Assessment, Nursing Diagnosis, Planning, Intervention, and Evaluation.
This is a behind the scenes view of the activity that you the patient may or may not know that you are participating in during your illness. It is meant to help to educate and prepare you to care for yourself with any new illness or diagnosis . And to help return you to your optimum health status.
When your nurse first meets you, she has already begun the nursing process and is making a nursing* ASSESSMENT – when she has collected the initial data about you. Your chart and records will show her why you have been admitted to the hospital, the diagnostic evaluation that is in progress or the diagnosis that has been made by your physician.
On admission a complete physical assessment is done by your admitting nurse. Your personal data base is confirmed with you . Asking you about you physical history, including asking you questions regarding allergies or any other illness that you might have. With what seems like redundancy on the part of the health care system is actually a verification process in place, that will be repeated over and over again while you are in the health care system.
During the time your registered nurse is spending with you she is using her refined observational skills. Assessing what your specific problems are and prioritizing them. The most critical determinations that she is making is related to your clinical stability and any pain you may be experiencing. Any physiological problems related to immobility or special needs are included in her assessment. The* NURSING DIAGNOSIS -is then determined and prioritized.
*PLANNING -is the next step in the nursing process to promote health, by reducing or resolving problems, and are related to appropriate interventions designed in the plan . Written plans are then put in place according to their priority. It is critical to be aware that you as the patient and your family should have the opportunity to be part of the care plan. Your personal goals are as important as those of the health care system. This is also part of the psychosocial assessment and is critical to the over all wellness of you the patient.
*INTERVENTION-Is the implementation of the plan of care. This is an ongoing process requiring updates in the care plan when any new problems arise. Documentation must take place to show resolution or intervention for newly developed problems.
*EVALUATION- is another part of the nursing process and is ongoing. It measures to what extent goals have been reached as established in the plan of care. It may identify negative factors that have interfered with the goal. Requiring the modification of the care plan.
This active nursing process is a tool that is used by all those giving care to you the patient. Changing shifts in the hospital setting, will refer to it often. and contribute to the attainment of the goals within the plan. Other areas of care such as physical therapy and nutritional intervention may be incorporated into the care plan when identified as a need, The professional goal of the NURSING PROCESS is to design a plan for collaborative care of professionals and a positive outcome for you the patient. The goal being the return to your optimum health status.