In the professional role of nursing there is uniformity in the practice of the nursing process. The nursing process has a significant place in the delivery of quality nursing care. Using the steps in the nursing process, assures the delivery of uniform holistic care to clients, families and the community at large.
As each client, family and illness is unique the steps used in the nursing process assures the personalization of a plan of care with objectives defined and then implemented. The goal being to return the individual to their optimum health status.
The nursing process includes critical thinking,clinical judgment,and the use of acquired clinical assessment skills. Using technical competence, and refined interpersonal skills, the professional nurse can collect important clinical and social information on a client and family, leading to a conclusion, and making a nursing diagnosis.
The nursing process focus is on both the physical and psychosocial needs of the client and family.
Actual or potential problems are identified. Pain and the possible causes, physical limitations, visual or hearing impairments that alter communication ability, nutritional deficits, and the mental status of a client are included in the nursing assessment.
Collection of important data:
*Obtaining a health history regarding / allergies/ illness/ medications /diet
Multiple nursing diagnoses can be made for a plan of care and are designed to deliver care beginning with the highest priority, that of greatest severity. In each illness there can be many steps in place to correct the clients problems. The devised plan of care uses standardized language with consistent terminology,definition and nursing interventions to reach desired outcome goals.
Be aware of the differentiation between a medical diagnosis and a nursing diagnosis.
“ A medical diagnosis is based on the physiological or the medical condition. The nursing diagnosis on the other hand is based on the alteration in health, the medical condition.”
The nursing care plan is put into action by the nursing staff by implementing steps consistently during the clients care. There are often several areas being addressed in a plan of care. Each step is measurable and eliminated once it is resolved and the desired goal has been achieved.
Documentation with an ongoing evaluation by professional nurses, assesses the clients response to the plan of care or the need to make changes in the plan if the desired response is not achieved.
See this link below for a sample nursing care plan for a client with congestive heart failure.
All members of an interdisciplinary team who are involved in the care of a client can contribute to the plan or make appropriate evaluations and revisions. This is collaborative care and is ideal in the delivery of high quality health care.