Developing An Appropriate Nursing Diagnosis

The first step in the nursing process is assessment due to the fact that assessment is seeing the patient and determining what level and type of care needed (Jordan, 1999, p.12). The nursing process is a process used by nurses to integrate all aspects of assessment into one single guideline. There are 5 stages to the

It is essential as a Registered Nurse and nursing student to ensure that a comprehensive safe and quality of practice is achieved, resulting in goals and outcomes being met positively improving the nursing needs of people. This standard is important to my scope of practice, as being a nursing student it is for me to ensure goals and outcomes are being achieved to ensure the safety and wellness to those I am caring for.

Quality of care in nursing is the ability to provide what is necessary for the health, welfare, maintenance, and protection of each patient, it is the capacity to satisfy their needs and to provide a care that is beyond their expectations. The care has to be organized, personalized, and appropriated for each patient.

The second step that I used in the nursing process was diagnosing. Based on my results from my assessment, I was able to use that information to come up with a couple nursing diagnoses. This step is used to offer effective nursing care because it helps me set an intervention and plan of care to help my patient’s health outcomes for the better.

Assessment of a patient is a big process of decision making, it is about the collection of information which will contribute to an overall judgement of a person and the illness they may have. Lloyd (2010) states that assessment is one of the first steps which is needed to be done in the nursing process, it is a building block for a relationship and an ongoing process which lets health professionals gather the correct information to help them understand the problems and needs that the patient is going through. Most of the nursing assessment which are in use today will all have very similar aims. The difference is that how the assessment’s are carried out is where the differences come from.

Codes of practice enables professionals to work effectively at high standards, respect and minimise risk to people that are in their care. Many care systems produce codes of conduct including The Nursing and Midwifery Council, nurses and midwives have to abide

Nursing sensitive indicators include the configuration, process and outcomes of nursing care. The configuration of nursing care concludes the nursing staff, their nursing skills, and the level of education that each nurse holds. The process of nursing care concludes the nursing assessments, intervention and implimentation. The outcome of nursing care either positive or negative depends on the quantity and quality of the care provided to the patients by the nursing staff ("Nursing world," 2013)

Assessment in the nursing process will establish the patients' ongoing needs and provide a quality of care best suited to the individual, to achieve a desirable health outcome.

Nursing care is focused on the assessment, nursing diagnoses, planning, implementation, and evaluation of patients. This nursing process can also be implemented in aspects outside of nursing and on the nursing field as a collective group. The nursing role is evolving, following the process the outcomes have to be evaluated and put into perspective. Research is being completed the conclusions are all the same, the higher education of nursing care the better the patient outcomes.

It begins with assessment and including an evaluation of the perceptions by the person, the person 's family, and the nurse. This is where subjective and objective data is gathered and recorded. It is a holistic assessment which covers the patient’s physiological, psychological, sociological, cultural and spiritual status. Information is collected by the nurse interviewing the patient, giving a physical exam, getting the patients’ health history and family history. For example, if a patient came into the hospital after a fall at home the nurse would start by gathering information that lead up to this point. The nurse would find out what the patients complications are from the falls, the frequency of falls, cause of the fall, or are there underlying causes. They would get medical history, family history, mental status, environment, and medications. The nurse would do a head to toe assessment and from there would begin diagnosing the patient appropriately.

The CNO outlined professional standards for nurses to comply with. The seven that are outlined are accountability, continuing competence, ethics, knowledge, knowledge application, leadership, and relationships. “A standard is an authoritative statement that sets out the legal and professional basis of nursing practice” (College of Nurses of Ontario, 2009, p. 3). Although each standard has different meaning, they all work together in order to provide the best possible patient care.

Our client, Ertha Williams is a 99 year old female who lives alone in a low-income apartment complex on the second floor in Monroe, Michigan. Ertha suffers from chronic kidney disease and has a history of hypertension and type one diabetes. Due to her chronic kidney disease Ertha has regular scheduled dialysis appointments three times a week, but since the death of her son and husband and her inability to drive it is difficult for Ertha to get to her dialysis appointments. She also has difficulties preparing the multiple medication she is required to take to manage her hypertension and diabetes. After her last dialysis appointment the nurse reported that Ertha appeared frail and emaciated. Ertha herself also stated that she worries about financial issues frequently and has good and bad days occasionally. Based on these findings Ertha is in need of some assistance to help alleviate some of the problems and stresses she is undergoing. Several nursing diagnoses can be established based on Ertha’s current situation and through these diagnoses it will be easier to establish what kind of services Ertha will need from the surrounding community of Monroe and what types of barriers she might encounter in attempting to access these services.

My two nursing diagnoses would be social isolation related to cultural difference as evidence by patient speaking Spanish as a first language. The rational for that would be that the no one can speak Spanish fluently and is a different culture from me. We would need to get an interpreter to help interpret for us between the patient and the healthcare team. They would need to book a service for someone to either come into the office or have them interpret over the internet like skype. I would evaluate it by seeing if the communication between the patient and the health care team is able to translate all the word and that the patient understands everything that is going on. My second one would be impaired verbal communication related to sensory

Assessment is described as”The first stage of the nursing process, in which data about the patient’s health status is collected” (Oxford dictionary of nursing, 2003, p23), following this phase a care plan can be devised.

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).