How To Write A Pak-Indo Subcontinent Culture Report
Pak-Indo Subcontinent Culture Report
Madiha Zaidi, Tameika Francis, Roselee St.Germain, Daniel Akinyimi, Troilina Ana, Rayshma Jagdat Saint Paul’s School of Nursing
NUR 100
Sarah Cheeky Arciaga, RN, MSN, MBA
The nursing process is a fundamental practice that is consistently utilized by professional nurses. It provides an organized structure for nurses to follow utilizing critical thinking and a problem solving approach in order to meet optimal patient care needs. The five phases within the process are to be followed in order, but maintain a cyclic course. According to Urden, Stacy, & Lough (2006), “the nursing process incorporates a feedback loop that maintains quality control of its decision-making outputs (pp. 8).
Assessment
The assessment phase …show more content…
of the Nursing Process is the fundamental basis for achieving positive patient outcomes. It involves a comprehensive holistic approach that incorporates data obtained from “biophysical, psychological, sociocultural, spiritual, and environmental characteristics” (Ackley & Ladwig, 2010, pp. 3). Objective data is obtained by reviewing a complete medical history, as well as performing a thorough head to toe examination of physical and psychological conditions such as mental status, vital signs, laboratory and test results, and inspection and auscultation of body systems (Ackley & Ladwig, 2010). In addition to this data, an integral part of the assessment phase is obtaining subjective information based on therapeutic communication with the patient and/or family. Initiating a trusting relationship, maintaining culturally accepted and appropriate body language, and attentive listening can promote an increased level of comfort within a patient to facilitate open-ended questions and dialogue. Questions should be directed toward the patient with the intent of obtaining health information that will provide additional details in the client’s immediate and overall health concerns. Professional nurses are required to maintain an appropriate level of clinical knowledge to ensure that their assessment approach and its findings are accurate, and relative to their scope of practice. Reassessment is necessary and should be performed as often as needed. This step in the nursing process is extremely important, as it is the foundation for all other phases within the process.
Diagnosis
One might question why a nursing diagnosis in addition to the medical diagnosis is assigned to a patient. What is the significance of a nursing diagnosis? A nursing diagnosis is a clinical judgment made about the individuals, families, communities, and/or environment the given patient is in and his/her responses to actual or potential health problems or life practices. Providing the basis of choosing the superlative nursing interventions to help accomplish outcomes for the given scenario (Herdman). Nursing diagnosis helps explain real time and also predicted signs, obstacles, or needs the patients may have. It shall not be seen as another way of affirming the medical diagnosis; it is independent from all other professions and limited to the nursing profession. However implementation of the nursing diagnosis may require at times a interdisciplinary effort. The nursing diagnosis is a judgment formed by the nurse, after a comprehensive assessment. Medical diagnosis is an imperative piece in the puzzle of the nursing diagnosis but it is not as detailed nor accurate in making the required nursing diagnosis. A medical diagnosis of diabetes mellitus for a new patient is not sufficient to make a nursing care plan for the said patient. The nurse must assess the understanding of the disease by the patients, asses resource the patient has to his/her disposal, coping mechanisms, teaching on administering insulin, and potential risk to injury the patient may have. A nursing diagnosis will be formed based on issues or potential problems recognized by the nurse. The care plan will be developed to address the nursing diagnosis of such problems and on the basis of the medical diagnosis of diabetes mellitus. Nursing diagnosis will consist of the problem and its cause, i.e. Powerlessness r/ t perceived lack of personal control (Ackley, 2013). In this diagnosis the nurse has identified the feeling of helplessness by the patient level due to psychological lack of control. The nursing diagnosis can be limited to one or many depending on factors observed by the nurse. The next phase of the nursing process will help formulate a plan on how to address the said issue or issues.
Planning
The next step after the diagnosis process has been completed is the planning phase of the nursing process. The nurse now creates a nursing care plan for the patient health issues and treatment. Using standardize nursing language such as Nursing Outcome Classification (NIC) and Nursing Intervention Classification (NOC) the nurse incorporates the diagnosis and assessment along with the patient’s goals for treatment. The nurse looks at the patient’s ability to help with care and what assistance may be needed to achieve the goals created, the care plan is then tailored to the specific patient. This step enables the beginning of the healing process and helps create a relationship between the nurse and patient.
Implementing
The implementing step is when the care plan is put in action. In the implementation phase the nurse looks at what is needed to follow the care plan, the nurse will determine what other healthcare personnel is needed, what needs to be delegated and what assistive devices may be needed. The nurse uses the care plan as guide for care, following the interventions to achieve the goals created. The nurse will education the patient on the diagnosis and the interventions being used. The nurse monitors these interventions and documents all care given this will ensure that all goals can be met.
Evaluation As the final step in the nursing process, the Evaluation step is essential in determining whether the interventions chosen have been effective in improving the patient 's condition.
The nurse evaluates the Outcomes portion of the nursing process to determine if the Interventions chosen were appropriate to achieve the goal. During the Evaluation phase, the nurse must have specific and complete qualitative and quantitative information about the data including lab results, vital signs, measurable assessment data, etc. The nurse not only uses critical thinking skills to evaluate the patient outcomes, but also uses acquired clinical decision-making skills to revise care based on the results of the evaluation. (Huckabay, 2009) According to Huckabay (2009), "Each of the steps of the nursing process requires the nurse to think critically and to reason accurately." (p. 72) It is important to note that the Evaluation step can actually be integrated throughout the entire process. Nurses can evaluate each step of the process to determine whether to proceed.
References
Ackley, B. J., Ladwig, G. B. (2010). Nursing Diagnosis Handbook (10th ed.). Maryland Heights, MO: Mosby
Elsevier.
Ackley, Betty J.; Ladwig, Gail B. (2013-01-20). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (Kindle Location 5943). Elsevier Health Sciences. Kindle Edition.
Forsyth, Marianne C,R.N., M.A. (1985). What is nursing diagnosis? Occupational Health Nursing, 33(8), 381. Retrieved from http://search.proquest.com/docview/1013443232?accountid=458
Herdman, T. H. (2008). Nursing diagnosis: Is it time for a new definition? International Journal of Nursing Terminologies and Classifications, 19(1), 2-13. Retrieved from http://search.proquest.com/docview/194498683?accountid=458
Herdman, T. H. (2013). What is Nursing Diagnosis and Why Should I Care?. Retrieved from http://www.nanda.org/What-is-Nursing-Diagnosis-And-Why-Should-I-Care_b_2.html
Huckabay, Loucine M, RN, PNP,PhD., F.A.A.N. (2009). Clinical reasoned judgment and the nursing process. Nursing Forum, 44(2), 72-78
Urden, L. D., Stacy, K. M., & Lough, M. E. (2006). Thelan’s critical care nursing: diagnosis and management (5th ed.). St. Louis, MO: Mosby Elsevier.
Madiha Zaidi, Tameika Francis, Roselee St.Germain, Daniel Akinyimi, Troilina Ana, Rayshma Jagdat Saint Paul’s School of Nursing
NUR 100
Sarah Cheeky Arciaga, RN, MSN, MBA
The nursing process is a fundamental practice that is consistently utilized by professional nurses. It provides an organized structure for nurses to follow utilizing critical thinking and a problem solving approach in order to meet optimal patient care needs. The five phases within the process are to be followed in order, but maintain a cyclic course. According to Urden, Stacy, & Lough (2006), “the nursing process incorporates a feedback loop that maintains quality control of its decision-making outputs (pp. 8).
Assessment
The assessment phase …show more content…
of the Nursing Process is the fundamental basis for achieving positive patient outcomes. It involves a comprehensive holistic approach that incorporates data obtained from “biophysical, psychological, sociocultural, spiritual, and environmental characteristics” (Ackley & Ladwig, 2010, pp. 3). Objective data is obtained by reviewing a complete medical history, as well as performing a thorough head to toe examination of physical and psychological conditions such as mental status, vital signs, laboratory and test results, and inspection and auscultation of body systems (Ackley & Ladwig, 2010). In addition to this data, an integral part of the assessment phase is obtaining subjective information based on therapeutic communication with the patient and/or family. Initiating a trusting relationship, maintaining culturally accepted and appropriate body language, and attentive listening can promote an increased level of comfort within a patient to facilitate open-ended questions and dialogue. Questions should be directed toward the patient with the intent of obtaining health information that will provide additional details in the client’s immediate and overall health concerns. Professional nurses are required to maintain an appropriate level of clinical knowledge to ensure that their assessment approach and its findings are accurate, and relative to their scope of practice. Reassessment is necessary and should be performed as often as needed. This step in the nursing process is extremely important, as it is the foundation for all other phases within the process.
Diagnosis
One might question why a nursing diagnosis in addition to the medical diagnosis is assigned to a patient. What is the significance of a nursing diagnosis? A nursing diagnosis is a clinical judgment made about the individuals, families, communities, and/or environment the given patient is in and his/her responses to actual or potential health problems or life practices. Providing the basis of choosing the superlative nursing interventions to help accomplish outcomes for the given scenario (Herdman). Nursing diagnosis helps explain real time and also predicted signs, obstacles, or needs the patients may have. It shall not be seen as another way of affirming the medical diagnosis; it is independent from all other professions and limited to the nursing profession. However implementation of the nursing diagnosis may require at times a interdisciplinary effort. The nursing diagnosis is a judgment formed by the nurse, after a comprehensive assessment. Medical diagnosis is an imperative piece in the puzzle of the nursing diagnosis but it is not as detailed nor accurate in making the required nursing diagnosis. A medical diagnosis of diabetes mellitus for a new patient is not sufficient to make a nursing care plan for the said patient. The nurse must assess the understanding of the disease by the patients, asses resource the patient has to his/her disposal, coping mechanisms, teaching on administering insulin, and potential risk to injury the patient may have. A nursing diagnosis will be formed based on issues or potential problems recognized by the nurse. The care plan will be developed to address the nursing diagnosis of such problems and on the basis of the medical diagnosis of diabetes mellitus. Nursing diagnosis will consist of the problem and its cause, i.e. Powerlessness r/ t perceived lack of personal control (Ackley, 2013). In this diagnosis the nurse has identified the feeling of helplessness by the patient level due to psychological lack of control. The nursing diagnosis can be limited to one or many depending on factors observed by the nurse. The next phase of the nursing process will help formulate a plan on how to address the said issue or issues.
Planning
The next step after the diagnosis process has been completed is the planning phase of the nursing process. The nurse now creates a nursing care plan for the patient health issues and treatment. Using standardize nursing language such as Nursing Outcome Classification (NIC) and Nursing Intervention Classification (NOC) the nurse incorporates the diagnosis and assessment along with the patient’s goals for treatment. The nurse looks at the patient’s ability to help with care and what assistance may be needed to achieve the goals created, the care plan is then tailored to the specific patient. This step enables the beginning of the healing process and helps create a relationship between the nurse and patient.
Implementing
The implementing step is when the care plan is put in action. In the implementation phase the nurse looks at what is needed to follow the care plan, the nurse will determine what other healthcare personnel is needed, what needs to be delegated and what assistive devices may be needed. The nurse uses the care plan as guide for care, following the interventions to achieve the goals created. The nurse will education the patient on the diagnosis and the interventions being used. The nurse monitors these interventions and documents all care given this will ensure that all goals can be met.
Evaluation As the final step in the nursing process, the Evaluation step is essential in determining whether the interventions chosen have been effective in improving the patient 's condition.
The nurse evaluates the Outcomes portion of the nursing process to determine if the Interventions chosen were appropriate to achieve the goal. During the Evaluation phase, the nurse must have specific and complete qualitative and quantitative information about the data including lab results, vital signs, measurable assessment data, etc. The nurse not only uses critical thinking skills to evaluate the patient outcomes, but also uses acquired clinical decision-making skills to revise care based on the results of the evaluation. (Huckabay, 2009) According to Huckabay (2009), "Each of the steps of the nursing process requires the nurse to think critically and to reason accurately." (p. 72) It is important to note that the Evaluation step can actually be integrated throughout the entire process. Nurses can evaluate each step of the process to determine whether to proceed.
References
Ackley, B. J., Ladwig, G. B. (2010). Nursing Diagnosis Handbook (10th ed.). Maryland Heights, MO: Mosby
Elsevier.
Ackley, Betty J.; Ladwig, Gail B. (2013-01-20). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (Kindle Location 5943). Elsevier Health Sciences. Kindle Edition.
Forsyth, Marianne C,R.N., M.A. (1985). What is nursing diagnosis? Occupational Health Nursing, 33(8), 381. Retrieved from http://search.proquest.com/docview/1013443232?accountid=458
Herdman, T. H. (2008). Nursing diagnosis: Is it time for a new definition? International Journal of Nursing Terminologies and Classifications, 19(1), 2-13. Retrieved from http://search.proquest.com/docview/194498683?accountid=458
Herdman, T. H. (2013). What is Nursing Diagnosis and Why Should I Care?. Retrieved from http://www.nanda.org/What-is-Nursing-Diagnosis-And-Why-Should-I-Care_b_2.html
Huckabay, Loucine M, RN, PNP,PhD., F.A.A.N. (2009). Clinical reasoned judgment and the nursing process. Nursing Forum, 44(2), 72-78
Urden, L. D., Stacy, K. M., & Lough, M. E. (2006). Thelan’s critical care nursing: diagnosis and management (5th ed.). St. Louis, MO: Mosby Elsevier.