Planning Nursing Care Nursing Process

AMERICAN NURSING HISTORY Planning Nursing Care Nursing Process Davida Michaels 3/20/2020 Contents Planning Nursing Care .................................................................................................................... 3 Nursing Process .......................................................................................................................... 3 Background and History ............................................................................................................. 3 Closer Look at Steps of the Nursing Process .............................................................................. 5 Assessment .............................................................................................................................. 5 Diagnosis................................................................................................................................. 5 Organization - Classification Systems .................................................................................... 6 Planning .................................................................................................................................. 7 Planning – Goal Setting ......................................................................................................... 8 Implementation ....................................................................................................................... 9 Evaluation ............................................................................................................................... 9 References ................................................................................................................................. 10 2 Planning Nursing Care Nursing Process Planning for care begins on admission and is continually updated in response to condition changes. The nursing process is a systematic decision-making method focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health it-i is the essential core of nursing practice to deliver holistic, patient-focused care. Nursing process provides an organizing framework for the practice of nursing and the knowledge, judgments, and actions that nurses bring to patient care.” Background and History The term nursing process was introduced in 1955 by Lydia Hall who identified three steps of nursing process as: (1) observation, (2) administration of care and (3) validation. Hall viewed nursing as the three C’s: Core, Care and Cure. The core is the patient receiving nursing care. Goals are set by the patient rather than by any other person according to his or her feelings and values. Care is focused on performing the task of nurturing patients including comfort measures, patient instruction, and helping the patient meet his or her needs when help is needed. Cure refers to therapeutic interventions by medical professionals. Hall believed that the cure circle is shared by the nurse with other health professionals, such as physicians or physical therapists. In 1959, Dorothy Johnson described nursing as fostering the behavioral functioning of the client. Johnson identified three steps of nursing process: assessment, decision and nursing action.ii Johnson is 3 known for the development the Behavior System Model of Nursing which stressed the importance of research-based knowledge about the effect of nursing care on patients. When she first proposed the theory in 1968, she explained that it was to foster “the efficient and effective behavioral functioning in the patient to prevent illness.” The nursing process of the Behavior System Model of Nursing begins with an assessment and diagnosis of the patient. Once a diagnosis is made, the nurse and other healthcare professionals develop a nursing care plan of interventions and setting them in motion. The process ends with an evaluation, which is based on the balance of the subsystems.iii In 1961 Ida Jean Orlando-Pelletieriv introduced d the “Deliberative Nursing Process Theory- which included five stages: assessment, diagnosis, planning, implementation, and evaluation. (ADPIE ).Orlando’s nursing theory stressed the reciprocal relationship between patient and nurse; what the nurse and the patient say and do affects them both. The result was an effective nursing care plan that could be easily adapted when and if any complications arise with the patient,. v Listen to an oral history by Ida Jean Orlando - https://www.youtube.com/watch?v=w3Gn3Ph-00Q ] In 1963, Lois Knowles at the University of Florida used a five step nursing process called the ‘five Ds’: discover, delve, decide, do and discriminate”. The discover and delve steps are relates to assessment phase, decide is the planning stage, do is the implementation stage; discriminate is the evaluation phase of client responses to nursing interventions 4 In 1967—Helen Yura and Mary B.Walsh. published The Nursing Process, which identified 4 strategic nursing care steps – also referred to as APIE:- Assessment, Planning, Implement and Evaluation. Closer Look at Steps of the Nursing Process Assessment In Notes on Nursing, Florence Nightingale cautions: "But if you cannot get the habit of observation one way or other, you had better give up the [idea of] being a nurse, for it is not your calling, however kind and anxious you may be." vi Assessment establishes a data base by interviewing the individual and/or family members, observing their behavior and physical examination to identify problem(s). Assessment requires listening, critical thinking skills and data collection- subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight. Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. The data is recorded objectively and accurately – data is then organized and analyzed, to formulate a nursing diagnosis, goals and desired outcomes. Diagnosis In 1953, Virginia Fry and R. Louise McManus introduced the discipline-specific term “nursing diagnosis” to describe a step necessary in developing a nursing care plan. The nursing diagnosis was used to standardize and define the concept of nursing care. Their hope this would help to nurses earn professional status.vii In 1972, the New York State Nurse Practice Act identified diagnosing as part of the legal domain of professional nursing. The Act was the first legislative recognition of nursing’s independent role and diagnostic function. viii Shoemaker defines a nursing diagnosis as: 5 “A nursing diagnosis is a clinical judgment about an individual, family or community which is derived through a deliberate, systematic process of data collection and analysis. It provides the basis for prescriptions for definitive therapy for which the nurse is accountable. It is expressed concisely and it includes the etiology of the condition when known.”ix The North American Nursing Diagnosis Association (NANDAx) defined the difference between a medical and nursing diagnosis as: “A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processesxi. For example, a medical diagnosis of Cerebrovascular Attack (CVA or Stroke) provides information about the patient’s pathology. The complimentary nursing diagnoses of Impaired verbal communication, risk for falls, interrupted family processes and powerlessness provide a more holistic understanding of the impact of that stroke on this particular patient and his family – they also direct nursing interventions to obtain patient- specific outcomes.”xii Nurses formulate nursing diagnosis based on their assessment of an individual for a problem or problems caused by their disease ,condition or disorder. Using this data they can formulates one or more nursing diagnosis. Nursing diagnosis are the basis for establishing and carrying out a patient care plan..xiii Organization - Classification Systems Development of a nursing nomenclature and classification system began as a movement to develop a language that would describe the clinical judgments made by nurses. There was great support by clinicians for describing problems that nurses are educated and licensed to treat which are not in medical language systemsxiv The North American Nursing Diagnosis Association (NANDA) is recognized in this and other countries as the pioneer in diagnostic classification in nursing. It began as a Task Force that was created at the First National Conference on Classification of Nursing Diagnoses, in 1973, and evolved into an incorporated Association in 1982 to assist nurses in the United States and Canada in classification. Initiation of work on classification for the nursing profession can be attributed to the foresight of two faculty at St. Louis University, Kristine Gebbie and Mary Ann Lavin who called the first conference on classification.xvxvi 6 In 1982, the conference group accepted the name “North American Nursing Diagnosis Association (NANDA)” to recognize the participation and contribution of nurses in the United States and Canada. In 1984, NANDA renamed “patterns of unitary man” as “human response patterns” based on the work of Marjorie Gordon. Currently, the taxonomy is now called Taxonomy II. In 1990 during the 9th conference of NANDA, the group approved an official definition of nursing diagnosis: “Nursing

Load more