The phases of the nursing process are:
collection and data analysis
nursing diagnosis
planning
implementation
Final Evaluation
The assessment consists of collecting and classifying data and leads to the next stage which is the diagnosis. Then the nurse provides the care plan, then the execution (or intervention). Evaluation is the last phase. Collect data and information continuously and recorded appropriately. The care plan must describe the objectives developed resulting from nursing diagnoses. The care plan must include the priorities of the actions needed to achieve certain objectives. The same user must be involved in its promotion of health, and work on your healthcare team.
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The collection and collation of data are guided by the fundamental concepts of the nursing discipline and are aimed at obtaining information concerning the patient, considering the fattoti physical, psychological, sociocultural and emotional that may affect your health. The assessment is also used to investigate the degree of autonomy of the individual in meeting the need, in order to express an opinion with clinical and plan actions so that they support, guidance, compensation or replacement.
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The data collection relies on observation, interview and physical examination. At this stage, you can refer to the classification of needs Maslow, that all men have in common a hierarchy of basic needs to satisfy. This scale of needs is divided into five levels:
Physiological needs
Needs for security and protection
Needs of belonging
Self-esteem needs
Needs for self-
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For data collection, observation produces objective data. The subjective data are reported directly by the user and the family. Other useful information is obtained from previous medical records, from professional journals and specialized books. State of the skin, complexion, body temperature, difficulty in breathing, and so on are to be taken into account in this first phase of the nursing process.
In the interview it is important to ask questions and listen. Applications must be placed so as to have a more comprehensive as possible, to complete the picture of health in a comprehensive manner.
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With the examination gather more objective data. In this case it must ensure a good user's privacy, eliminating every form of interference with the external environment. Generally you use the approach cephalocaudad, but then consider first what in that moment deserves the highest priority, as it may be a bleeding wound or drainage from medicare. We use the auscultation using a stethoscope to listen to the sounds coming from the intestines, heart and lungs. By palpation are obtained information on the consistency of organs, their position, abdominal contraction and the presence of pain. Furthermore, the percussion can sense the presence of intestinal gas if it receives a sound like a drum.
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Making nursing diagnosis means to describe the responses, the signs, symptoms that indicate an actual or potential (risk) health problem and identify the most appropriate care to solve it.
The formulation of nursing diagnosis is a logical extension of data collection relating to the establishment. During the investigation have asked any question relating to history, played every technical examination on the physical conditions, taking into account any result of laboratory tests and performed a careful and insightful individual over the general conditions ...
Through:
Analysis of data
Interpretation of data collected
Identification of the problem
Formulation of objectives
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It 'a process of data analysis and identification of problems in that it uses to make judgments on your responses in the face of problems or potential problems. The data collected are then analyzed to verify their accuracy. In case of incompleteness, omissions or inconsistencies, we must go back to collect the missing data. Then it determines if the data are normal, if the state of health of the user has altered from the past. So, we identified areas that require nursing intervention. To do this, we use the theories of nursing, scientific principles and experience. Recall that the nursing diagnosis is the detection of a real or potential problem that requires intervention of the nurse to be solved completely or partially. To make such diagnosis, insight into the area where you are, we resort to models released by NANDA. There are various types of nursing diagnoses identified, the NANDA we propose three models of diagnosis.
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Current or real-represent a condition clinically validated.
Risk or high risk - consist in clinical judgment according to which a person, a family or a community is vulnerable to a certain problem.
Welfare - consist of a clinical judgment about a person, a family or a community in transition from a specific level of welfare to a higher level. Therefore relate to the diagnosis related to health promotion. In this case must be present two elements:
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the desire for a greater level of wellness
the presence of a condition or function effectively, that is, personal and environmental potential to improve the situation
The collaborative problems are, finally, issues that are treated in collaboration with other specialists. Doctors prescribe certain treatments and cures, but then it is up to the nurse running them and adapt to the situation.
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The actual diagnosis is constructed by combining the user's problem with the causes (if known). If the problem is the lack of skin integrity and the cause is immobility, the diagnosis will be real: poor skin integrity due to physical immobility. With a similar model, called PES, leads to the pooling problem diagnosis, etiology, signs and symptoms: poor skin integrity due to physical immobility, which is manifested by skin ulceration of the elbows and coccyx.
In summary, to formulate a nursing diagnosis should follow the following points:
review the data collection
identify a problem
See the list of NANDA
determine the cause, if known
signs and symptoms, if necessary
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the third phase of the nursing process is given by the schedule. It is estimated, at this level, your ability, family, nursing staff available, the required equipment, personal skills, values and beliefs. The plan will be drafted to ensure that assistance is personal and realistic. The planning stages:
set priorities, in the case of many needs
setting goals
plan the nursing intervention
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Priorities may be of high, medium and low. Will clearly meet the basic needs before those of secondary and some needs are interrelated, and satisfying the one you can not solve the other. When talking about needs, you think of Maslow's hierarchy, which can be used as a reference for planning nursing care. They fit well, the objectives to involve the user and to ensure full collaboration with the healthcare team. The nurse must be able to educate the user and the family of those that are the priority at that time. The aim of nursing is the expected result of nursing care plan, which aims to prevent and resolve the problem diagnosed the patient as possible. The goal is a guide for selection of nursing interventions, and a constant reference to highlight improvements in user. For each diagnosis is defined at least one goal. The objectives consist of the user's behavior, the performance criteria, deadlines and conditions. User behavior is observable because it expressed something yourself. The performance criteria are the standard levels of user behavior, to which you want to get there (a pressure of 140/80 for example). The deadline is the time within which you want to reach that particular goal.
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The objectives are divided into short-term and long term. The goals are somewhat consistent with other therapies (possibly support), as well as realistic for the ability of the patient and nurse.
Set goals are planned nursing interventions. The interventions are by definition specific activities planned and implemented with the method, to help you achieve your objectives. Interventions must include what should be done, when to do it, how often, any activity that precedes and follows the action in nursing, nurse's signature. Nursing interventions are based on scientific principles and knowledge. The nursing intervention must not deviate from those that are medical guidelines (requirements ...). You can refer to standards of care plans as a guide to writing a personalized care plan.
The implementation of the nursing care plan is the fourth phase of the nursing process. Is a review of the plan, the drafting, implementation and documentation of care and constant data updates. First we have to establish that the plan is safe for the user, based on scientific principles secured with nursing diagnosis supported by the data, priorities and objectives consistent with the needs identified by the diagnosis, goals with time references, nursing actions with logical sequence and personalized assistance. The last stage of implementation of the plan is recording operations performed on users. What we need to consider is that there shall be one continuous data collection throughout the execution of the plan of care.
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The last phase of the nursing process is the evaluation, where we endeavor to ensure the achievement of objectives and a practical plan review. It assesses the extent to which the objective was achieved, and the behavior that manifests the'' user. The review before the repetition of the various phases of the nursing process, whether the objectives were achieved, and if they are not being met. This makes it clear that the process of nursing is something sequential, but also cyclic.
In short
Contains the written formulation of the entire nursing process, the aims and objectives of the services provided to the user, based on the needs identified and diagnoses derived from these. Evaluate the residual capacity of the individual and determines the activities required to attain the set goals, expressed in terms of expected results. Must be drafted in a clear, flexible, well-defined, must consider the human and material resources available and should establish the criteria for evaluating the effectiveness of the intervention (outcome indicators). Apply the scientific method of problem solving (problem solving) and used as a starting database of the history of nursing. Graphically it can be summarized into four "pillars": nursing diagnosis (or problem related to the need), Objective (expected results in the short, medium or long term, with the adoption of performance indicators), Intervention (related to the problem and made dependent on 'objective, planned activities and the individual execution times) and Verify (analysis of performance indicators and eventual return to the previous phases, with the reassessment of objectives and interventions).
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