Extent of Utilization of the Nursing Process in the Nursing Documentation of the Professional Nurses at Seamen’s Hospital

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CHAPTER I
THE PROBLEM AND ITS BACKGROUND

Introduction
Nursing is the process of caring for, or nurturing, another individual. In order to render care to an individual, the nurse should apply the art and science of nursing that includes the therapeutic use of self, apply and perform different nursing procedures, critical thinking skills, communication and assessment skills, proper and accurate documentation and most importantly, the practice and use of the nursing process. (Berman, A., Snyder S. J., Kozier, B. & Erb, G.(2008). Kozier and Erb’s Fundamentals of Nursing. 8th Ed. Jurong, Singapore: Pearson Education South Asia Pte Ltd.)

According to Andres (2007) one of the functions of the nurse is the documentation of the client’s health status. Of all the client’s medical attendants, the nurse is with him most of the time. For the reason, the quality of her observations and reports, written and oral are of utmost importance.

Moreover, for a documentation to be effective and to be able to solve the client’s potential and actual health problem, critical thinking skills and the use of the nursing process must be used. It provides a systematic framework in rendering professional and quality nursing care and also the integral part of the nursing practice. Thus, it must be given with utmost attention and should be practiced in the clinical setting. This scientific-based process aims to solve the current and potential health problems of the client leading to individualized, holistic, effective and efficient care to clients. In the Philippine hospital setting, nurses spend more time in doing the charting rather than the ideal that is spending more time together with the client. In here, if the nursing process is properly utilized in the documentation, there will be more time for the nurse and the client to interact with each other so as the needs of the client be addressed, further quality nursing care will be rendered and the client’s actual or potential health problem will be solved. The said scientific-based process will give the nurse a direction and a systematic framework in attending the needs and problems of the client. However, critical thinking skills must be used in order to follow the nursing process accurately and correctly. Furthermore, in every area or ward in an institution, there are different types of documentation technique that is being used. Also, it is vital for nurses to use the nursing process since it has been in the nursing curricula and is essential in the standard of the nursing practice. Even if there are certain types of documentation technique, still it must be utilized by the nurses in order to give holistic, individualized and problem-oriented care following the standard of the nursing practice. With unexpected instances that happened during the course of care of the client, the researchers came up with this study entitled “Extent of Utilization of the Nursing Process in the Documentation of Professional Nurses at Seamen’s Hospital” to figure out if the nurses still apply and follow the nursing process and also, find out the essential role of it in nursing documentation and in the nursing care and its importance in the nursing practice.

Background of the Study
Nursing profession is a combination of art and science. Different techniques, skills and knowledge especially the critical thinking skills are required in order to be considered as a competent nurse. However, as a nurse, knowledge on the importance and the use of the nursing process is vital in giving quality nursing care. Moreover, for the professional nurses, in their everyday shift and hours of duty, documentation is a task that must be done correctly, accurately and in an organized manner. With this, in order for them to use and manage their time effectively, the nursing process takes in together with the use of the critical thinking skills that every nurse possesses. With the use of the said scientific-based process, it...
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