nursing process writing assignment

Topics: Nursing, Nursing care plan, Problem solving Pages: 5 (688 words) Published: February 26, 2015
Running Head: ASSESSMENT AND DIAGNOSIS COMPONENTS

Assessment and Diagnosis Components of the Nursing Process
Aldecia Blackwood
ITT Technical Institute

ASSESSMENT AND DIAGNOSIS COMPONENTS

Abstract
The nursing process is an organized critical thinking system used by professional nurses to give the best optimal care to clients. “It is very similar to the steps used in scientific reasoning and problem solving.” (Ackley and Ladwig, 2014:2). It contains five steps; Assessment, Diagnosis, plan, implementation of care, and evaluation. Assessment is collected first by doing a health and medical history, and by listening to and observing the client. To obtain as much information as possible to start the process, several open-ended questions are asked. Data is also obtained from physiological factors; taking vitals, and doing diagnostic test. “In the nursing diagnosis phase of the nursing process, the nurse begins clustering the information within the client story and formulates an evaluative judgment about a client’s health status.” (Ackley and Ladwig, 2014:3). Assessment and diagnosis are the first two main important steps of the nursing process where the foundations of all care plans are developed.

ASSESSMENT AND DIAGNOSIS COMPONENTS

Assessment and Diagnosis Components of the Nursing Process
Nursing process is an organized system that is used in the practice of nursing. It involves all the steps taken by a nurse when performing care for a patient: Assessment, nursing diagnosis, planning, implementation, and evaluation. This process uses a systemic process to each individual situation, commencing with assessment, including evaluation and a reconciliation of the patient, their family members and the nurse. “It is very similar to the steps used in scientific reasoning and problem solving” (Ackley and Ladwig) . Each step follows each other at the beginning of the process but may need to be concurrent in different situations. In this paper Assessment and Diagnosis will be further discussed.

The assessment step of the nursing process is the first step in delivering care. This does not only include physiological data but also psychological, sociocultural, spiritual, economic, and life-style factors as well. “The nurse assesses components of the patient’s story every time they perform an assessment. Often, nurses focus on the physical component of the story (e.g., temperature, blood pressure, breath sounds). This component is certainly critical, but it is only one piece. Indeed, one of the unique and wonderful aspects of nursing is holistic theory that is applied to clients and families” (Ackley and Ladwig, 2014:3). This information is also known as objective data, and all of this information will be used to formulate a diagnosis.

In the diagnosis category of the nursing process the nurse’s clinical judgment and concerns about the client are main aspects of formulating diagnosis. Diagnosis does not only reflect only the signs of a patient’s sickness but also the symptoms of other problems that have developed. “Only after thorough analysis, which includes recognizing cues, sorting through and organizing or clustering the information, and determining client strengths and unmet needs can an appropriate diagnosis be made. This process of thinking is called clinical reasoning.” (Ackley and Ladwig, 2014:3). Clinical reasoning is the ability to find clinical solutions to clinical problems as they occur, and the ability to take in to consideration what is important to the family members and client. Diagnosis is the most important reason for a nurses’ care plan.

The nursing process is an organized framework that professional nurses use to formulate care plans and help patients get back to optimum health. The steps of the nursing process are very important in planning a care plan, because without any assessment nurses would not know who they working with, or on and...

References: Ackley, B & Gail Ladwig (2014). Nursing Diagnosis Handbook. Maryland Heights, Missouri:
Elsevier Inc.
Mosby, E (2013). Mosby dictionary of Medicine, Nursing and Health Professions. St, Louis
Missouri: Elsevier Inc.
Nursing Process. (2015). retrieved January 20,2015, from American Nurse Association
Web Site: http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing/Tools-You-Need/Thenursingprocess.html
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