This is the first assignment of the concepts in nursing. The nursing process is a series of scientific steps that can be applied to a patient to fulfil his or her basic needs and helps to solve the clinical problem independently. It is based on a nursing theory developed by Ida Jean Orlando in the late 1950's. It is an essential part of the nursing care plan and consists of five steps. They are: assessment, nursing diagnosis, planning, implementation and evaluation. The nursing process highlights the patient as the central character and is directed at improving outcomes for the patient, and not about nursing goals. This assignment discusses the application of the nursing process to a patient in a methodical way. Mrs. Magalika was admitted to the ward, which I was working. I would like to apply this nursing process properly to her. Mrs. Mangalika was admitted to the ward following a road traffic accident by the Police. She is a 32 years old mother of three children. She is a dancing teacher in a government school. Her husband is an army officer, who is currently serving in North. Her mother also lives with her family. She is 70 years old and has visual problems. During Mrs. Mangalika’s work hours her children are under the care of a domestic servant.
• To apply the nursing process to a given patient in a methodical way • To assess the condition of the client through collection of data • To analyse the client’s actual, potential and possible problems to develop a nursing diagnosis by gathering data • To describe the nursing care plan by prioritising the client’s needs and problems • To implement the planned client care
• To evaluate whether the implementation has achieved client’s goals and if not the nursing process should restart. • To improve the knowledge about the nursing process and promote the nursing care.
Assessment is the first step of the nursing process and it includes the systematic collection of data about the client. It is also used to help in identification of the person’s needs and strengths. The data can be collected according to the following main methods: 1. Data can be gathered through visual observations. This has the advantage of collecting data without confronting the client. However the amount of accurate data that can be collected is limited. Things that can be observed are: sex, appearance, mood etc. 2. The data is collected by interviewing the client. This will provide first hand information regarding the client. The limiting factor is that it needs to be assumed that the patient is telling the truth. Data that can be collected are: name, age, occupation, religion, ethnicity, family information etc. 3. Gathering of data can be done through consultation with another member of the health care team. This is useful if the client is unable to provide information for eg. in an unconscious state. This also has the limit of being able to give only the second hand data. 4. Data can also be collected by examination of the patient. This is done through inspection, palpation, percussion and auscultation. The clinical status of the patient can accurately be assessed through this method. To gather data the examiner must be skilled and competent with examination methods. The data that can be gathered are; pallor, palpable liver, ascites and heart murmur.
The patient is the primary source of information while all other sources are secondary. The collected data are mainly of two forms; subjective data and objective data.
This is data taken from the client and is the person’s own description of themselves. This depends on people’s perceptions, therefore can easy to get misleading data. Following are subjective data about Mrs. Mangalika:
• The middle age lady with well nourished and normal food habits. • Suffering from severe pain.
• Under sever stress