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The nursing process

explanatory Essay
1341 words
1341 words
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The standards of practice describe a competent level of nursing care as exhibited by the critical thinking model known as the nursing process. This practice includes the areas of assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The nursing process includes significant actions taken by registered nurses (RN) and forms the foundation of the nurse’s decision-making (“American Nurses Association,” 2010).

Assessment is the accurate collection of comprehensive data pertinent to the patient’s health or the situation (“American Nurses Association,” 2010). Assessment is the first step in the nursing process and the most important. Assessment is the accurate collection of the patient’s health date including both subjective and objective information. Subjective data includes information that can only be described or verified by the patient. This may include chest pain, headache, or body aches. Objective date is data that can be observed and measured. This type of data is obtained using inspection, palpation, percussion, and auscultation during the physical exam. Objective data can also be provided through diagnostic testing. This is important for proper diagnosis, planning, and intervention. Examples of this may include vital signs, warm and moist skin, and coughing up yellow colored sputum.

The second standard in the nursing process is diagnosis. During this step, the registered nurse analyzes the assessment data to determine the diagnosis or issues (“American Nurses Association,” 2010). Analysis involves recognizing cues, sorting through and organizing or clustering the information, and determining patient strengths and unmet needs. These findings are compared with documented norms...

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... directed by the client’s changing status throughout the process. The nurse may collaborate with the client, family, significant others, and other members of the health care team in applying steps of the nursing process. The following standards shall be used by a registered nurse, using critical thinking and clinical judgment in applying the nursing process for each client under the registered nurses care: assessment, analysis and reporting, planning, implementation, and evaluation (“Ohio Board of Nursing,” 2008).

As a registered nurse new to the practice, I try to implement the laws and standards of practice into caring for my patients on a daily basis. I try to adhere to the scope of practice and the rules and regulations. It is my obligation as a heath care professional to do what is in the best interest of my patient while staying within these guidelines.

In this essay, the author

  • Explains the nursing process, which includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation.
  • Explains that assessment is the first step in the nursing process and the most important. subjective data includes information that can only be described or verified by the patient. objective data is obtained using inspection, palpation, percussion, and auscultation during the physical exam.
  • Explains that the registered nurse analyzes the assessment data to determine the diagnosis or issues. this involves recognizing cues, sorting through and organizing or clustering information, and determining patient strengths and unmet needs.
  • Explains that nursing diagnosis is a clinical judgment about actual or potential individual, family, or community experiences/responses to health problems/life processes.
  • Explains the third standard of practice, outcomes identification, where the registered nurse identifies expected outcomes for a plan individualized to the patient or the situation.
  • Explains that the fourth standard of practice is planning. the nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.
  • Explains that the fifth standard of practice is implementation. the advanced practice nurse uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations.
  • Explains that the sixth standard of practice is evaluation. the nurse evaluates whether the patient's progress toward attaining outcomes is realistic, measurable, and achievable.
  • Explains that they are required at their facility to implement a nursing care plan based on their nursing diagnosis upon admission of patients. they evaluate goals that have been set and change what is unattainable for their patient.
  • Explains that the ohio board of nursing and the state revised code of rules require a registered nurse to provide nursing care within the scope of practice of nursing.
  • Opines that as a registered nurse new to the practice, they try to implement the laws and standards of practice into caring for their patients.
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