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