The nursing process Essay

Wilkinson, J. M., & Treas, L. S. (2016). Fundamentals of Nursing (3rd ed., Vol. 1). Philadelphia, PA: F.A.

The ASPIRE framework, also referred to as the nursing process (Barratt, Wilson and Wollands, 2012) was used to structure and develop Susan’s care plan. Introduced by Barrett, Wilson and Wollands (2012), following on from APIE developed by Yura and Walsh (1967), ASPIRE stands for assessment, systematic nursing diagnosis, planning, implementation, recheck and evaluation. Hogston and Marjoram (2006) believe that systematic nursing diagnosis was added to offer direction and time for the nurse to reflect on gathered information and systematically develop a diagnosis. Also the aspect of rechecking is to enable the nurse to monitor and plot a patient’s progress contributing to the final stage of evaluation of care and if its successfulness (Barratt, Wilson and Wollands, 2012).

The ultimate goal of nursing practice is to deliver high-quality nursing care and to improve health outcomes. As a nurse, I should be able to exercise my clinical judgment as I plan and provide care to my patient. Evidenced-based practices are the foundation of quality patient care which I must always support and rely on.

In standards terminology paper one patient’s assessment will be presented along with Nursing Diagnosis, Nursing intervention Classification and the Nursing Outcome Classification.

Standards of Care, used in conjunction with scope of practice, addresses the role and boundaries for acute and critical care nursing (Bell, French & Wilkins, 2008). Standards use the nursing process of assessment, diagnosis, outcomes, identification, implementation and evaluation, as a framework (Bell, French & Wilkins, 2008).

As a nurse, one must be aware of the Activities of Living (AoL), assessment methods and understand how to formulate a Nursing Care Plan (NCP). When tending to a patient, it is important to understand the AoL as well recognising how they are affecting the patient, how to assess one’s condition and what ‘care needs’ are priority when treating a patients symptoms. By having this knowledge a nurse is able to develop a NCP more easily, therefore give the patient a greater quality of care. When creating a NCP, one must assess, set goals, plan, implement and evaluate the measures taken as well as incorporate a multi-disciplinary team, to ensure the patient receives the best care possible. (Holland et al. 2015, p.2), (Doenges, ME, Moorhouse, MF, & Geissler-Murr, A 2002, p. 6).

Nursing terminologies also help nurses to plan care that reflects the patient’s needs, anticipate these needs, and intervene accordingly. In addition, nursing informatics makes the use of standardized terminologies more important than ever because it allows differentiating the impact of nursing care from those of other disciplines. Thus, the standardization of nursing terminologies with documented nursing diagnoses, nursing interventions, and patient outcomes is important to nursing practice because it unifies the language among nurses and other healthcare providers, which will have a positive impact on the quality of

The NANDA: Nursing Diagnosis Definitions and Classification are a critical component in the nursing process. This is the first step in identifying how we should plan nursing care for our patients’ to improve patient outcomes for which nurses are held accountable. It also helps us to identify what are the priorities in caring for this patient. Some of the components of a nursing diagnosis are the label or name and definition, related factors or risk factors, and defining characteristics. For this particular scenario some of the nursing diagnosis would be

An assessment is the first step in which a nurse gathers information about a patient in relation to their diagnosis and the presenting problems. It helps to formulate a nursing

Standards of care are the baseline for proving quality of care and govern the practice of nursing. Adherence to these standards helps ensure safety and achieving better client outcomes. The main purpose of standards of nursing practice to promote, guide and direct nursing practice. Provides framework for developing competencies; it outlines what the profession expects of its members to deliver quality of care and patient safety.

Nursing is an academic strictness and professional practice. It is a practice that has evolved throughout the years since the pioneering of Florence Nightingale. Nurses use critical thinking and judgment to deliver evidence-based care to individuals to attain a prime level of client wellness in diverse nursing situations. Although terminology and approach to health care varies within nursing, all fall within the metaparadigms of nursing. Depending on the detailed necessities of the patient, nurses must arrange these notions to deliver care in a way that best suits the situation.

The use of evaluative measures enables the nurse to determine the success or failure of the interventions based on whether the desired outcomes have been met. Critical reasoning allows the nurse to select the most appropriate evaluative measures, and helps guide the process of care plan revision, if necessary. Nurses “apply critical thinking as they mature, acquire knowledge and experiences, and examine their beliefs under new evidence” (Papathanasiou et al., 2014, p. 284). By evaluating the success of the nursing process, the nursing student gains critical

The nursing process steps in assessment, diagnosis, planning, implementing, and evaluation is the framework for patient-centered care. As I reflect back through my 44 three years of nursing practice with 34 of them as an OR nurse, I am most passionate about pain management even with all the challenges it imposes, and this is where I feel that my strongest assessment skills are. The foundation of our nursing profession it is not to only ask the questions and rely solely on the questions asked, but it imperative to listen to your patient. Taking into a count of the age the patients are often our teachers, we learn from them as we plan, implement, and evaluate they provide us with the tools that benefit us with others. Education is one of our

The CCC website (2012) describes this system of nursing terminology as a “unique coding structure for assessing, documenting, and classifying patient care by nurses and other clinical professionals in any health care setting” (www.sabacare.com). The CCC system serves nursing as well as other health care providers such as physical, occupational and speech therapists and medical social workers. The ICN website (2015) reports ICNP was created to improve worldwide healthcare as an integral part of the global information infrastructure to influence health care practice and policy. This database is intended for use by nurses, who can describe and report in detail, nursing assessments and interventions, as opposed to being a system for other clinical healthcare professionals. The ICNP is reported reliable to support care and effective decision making and useful for nursing education, research and health policy (www.icn.ch/what-we-do/about-icnpr/).

Nursing needs to describe exactly the scope of practice and measure its contribution to patient care. Without trusted and acceptable clinical data, no one would think that nurses make a difference. Using standardized language for nursing diagnosis and nursing interventions allows nurses ' activities to be described next to medical diagnoses and medical interventions, and their impact is measured in relation to patient outcomes. For example, chronic renal failure is a medical diagnosis identified by ICD-9 code #585 (CMS.GOV, 2012). Chronic renal failure is linked with the following nursing diagnoses: activity intolerance, decreased cardiac output, excess fluid volume, fatigue, imbalanced nutrition, impaired comfort, impaired urinary elimination, ineffective coping, the risk for infection, the risk for injury and the risk for noncompliance (CMS.GOV, 2012). Each North American Nursing Diagnosis Association nursing diagnosis can be connected to a series of Nursing Interventions Classification (NIC) nursing interventions. Each nursing intervention can be evaluated based on the available evidence and its appropriateness to the