Name: Khyra Ysabelle C.

Villanueva Date: February 19, 2022

Section: BSN-1A

WORKSHEET 1

NURSING PROCESS

Discuss the different phases of nursing process. 2 pages only Times New Roman 11, double spaced.

In the medical field, everything varies; every case has its own uniqueness; situations are fast-paced, that is

why it is important that health workers and staffs are knowledgeable on how they could effectively help each and

every person. But for nurses, one of the many things to remember is the nursing process. The nursing process is

one of the most important practices that a nurse must do so that they could systematically, methodically and

reasonably give care and solve the problems determining a patient’s health. This may vary depending on the

patient’s case and needs. It is also a cyclical, step-by-step plan that is composed of 5 basic components which are

the ADPIE or the initial Assessment of the patient, the determination of the nursing Diagnosis, Planning of health

care, Implementation of the said health care plan and the overall Evaluation of the patient who underwent with

the said plan.

The process starts with a critical and well-rounded Assessment. In assessing a patient, one must collect

enough data in order to determine a patient’s case. It is important that the data collected must be accurate and

detailed, information such as the person’s symptoms, health history, and the overall initial and final result of tests

if done. False or incorrect data will affect the remaining steps in the nursing process. The nurse is expected to

come up with systematic plans and goals in order to achieve efficient and effective humanistic care. Therefore,

one must be good at decision making and should be able to think critically, especially in worst case scenarios.

Assessing is done not only at the start of the nursing process but it will also affect the other components

drastically. A nurse should do the basic types of assessments which are the initial comprehensive, ongoing or

partial, focused or problem-oriented and emergency assessments in order to gather enough data to help the client.
 After assessing, the nurse must come up with a diagnosis based on the patient’s current state. The

subjective and objective data will make of what needs to be done. The nurse is then expected to analyze and come

up with a conclusion based on the information. They must set goals or anticipated outcomes, while still making

sure that the assessment is accurate and thorough as possible. They must identify the abnormalities that are

present and figure out what might be causing the problems encountered. A nurse will then propose their initial

diagnoses and will confirm their conclusions. Once this is accurately done, they may proceed with the making the

health care plan.

Planning means determining the outcome criteria and thoroughly developing a plan for the patient; will the

patient be admitted, or are they subjected to another test? What antibiotics will they be given and from the

diagnosis, what will be the most effective plan for the patient. This should be consulted with the patient’s doctor

because some nurses except for some advanced practiced ones, they cannot necessarily give any kind of

prescription, most especially antibiotics, without a physician’s order.

Once the plan is accurate and is approved by the doctor, it will now be implemented. Basically, this is

when the plan is conducted towards the patient. This may vary along the way depending on how the patient reacts

to the medication or intervention done. For example, if a certain medication was administered, it is the nurse’s job

to document it and monitor the client if he or she acted positively or negatively to the intervention. If ever the

patient had some kind of allergic reaction or his or her state was worsened, the nurse will then re-evaluate the

health plan until maximum health is reached.

Lastly, the patient will then be evaluated if whether or not the plan helped him or her recover; if the goal

was met and if there is any necessary changes that should and could be done to change or enhance the overall

plan of care. If ever the patient is now well by the end of the last step, he or she will most likely be discharged or

instructed to go home depending on the doctor’s orders.

References:

Weber, J., Kelley J. (2003) Health Assessment in Nursing (2 nd ed.). Philedephia: Lippincot Williams &
Wilkins (4-7)