The Nursing Process, also called Nursing Process (PE) or Nursing Care Process (PAE), is a systematic method of providing efficient humanistic care focused on achieving expected results, based on a scientific model carried out by a Nursing professional. . It is a systematic and organized method for administering individualized care, according to the basic approach that each person or group of them responds differently to a real or potential health alteration. It was originally an adapted form of problem solving, and is classified as a deductive theory in itself.
Features of the PAE:
- It has universal validity.
- Use terminology that is understandable to all professionals.
- It is centered on the patient, marking a direct relationship between the patient and the professional.
- It is oriented and planned towards the search for solutions and with a clear goal.
- It consists of five cyclic stages.
The use of the nursing process allows the creation of a care plan focused on human responses. The nursing process treats the person as a whole; The patient is a unique individual, who needs nursing care focused specifically on him and not only on his illness.
The nursing process is the application of the scientific method in the care practice of the discipline, so that systematized, logical and rational care can be offered, from a nursing perspective. The nursing process gives the profession the category of science.
Objectives of the PAE:
- Serve as a work instrument for nursing staff.
- Give the profession a scientific character.
- Encourage nursing care to be carried out in a dynamic, deliberate, conscious, orderly and systematized manner.
- Trace evaluable objectives and activities.
- Maintain constant research on care.
- Develop your own knowledge base, to achieve autonomy for nursing and social recognition.
The nursing process involves skills that a nursing professional must possess when he or she has to begin the initial phase of the process. Having these skills contributes to the improvement of the nursing professional’s attention to the patient’s health, including the patient’s level of health, or the patient’s state of health.
- Cognitive or intellectual skills, such as problem analysis, problem solving, critical thinking, and making judgments regarding client needs. Included among these skills are those of identifying and differentiating current and potential health problems through observation and decision making, by synthesizing previously acquired nursing knowledge.
- Interpersonal skills, which include therapeutic communication, active listening, sharing knowledge and information, developing trust or creating good communication ties with the client, as well as ethically obtaining necessary and relevant information from the client which will be later used in the formulation of health problems and their analysis.
- Technical skills, which include the knowledge and skills necessary to properly and safely handle and maneuver the appropriate equipment needed by the client when performing medical or diagnostic procedures, such as assessing vital signs, and administering medications.
PAE PHASES
1. ASSESSMENT PHASE
The assessment consists of collecting and organizing data that concerns the person, family and environment in order to identify human and pathophysiological responses. They are the basis for subsequent decisions and actions.
The professional must carry out a complete and holistic nursing assessment of each of the patient’s needs, regardless of the reason for the encounter. Usually, an assessment framework based on nursing theory or the Glasgow scale is used. This assessment considers problems that can be both real and potential (risk).
The following Nursing models are used to gather the necessary and relevant patient information to effectively provide quality nursing care.
- Gordon’s Functional Patterns of Health
- ROY adaptation model
- Models of body systems
- Virgina Henderson Needs Model
- Maslow’s Hierarchy of Needs
We can obtain the data from two sources:
- Primary sources: observation, physical examination, interrogation (direct or indirect), laboratory and office studies.
- Secondary sources: clinical record, bibliographic references (articles, journals, clinical practice guides, etc.)
The interview is a planned conversation with the patient to learn about their health history. On the other hand, it is a process designed to allow both the nurse and the patient to give and receive information; It also requires communication and interaction skills; It is focused on identifying the answers.
Interview objectives:
- It allows you to acquire the specific information necessary for the diagnosis.
- Facilitates the nurse/patient relationship by creating an opportunity for dialogue.
- It allows the patient to receive information and participate in identifying problems and establishing objectives.
- Helps determine specific areas of investigation during the other components of the assessment process.
2. DIAGNOSTIC PHASE
Nursing diagnoses are part of a movement in nursing to standardize terminology that includes standard descriptions of diagnoses, interventions, and outcomes. Those who support standardized terminology believe it will help nursing become more scientific and evidence-based. The purpose of this phase is to identify the patient’s Nursing problems.
Nursing diagnoses are always referred to human responses that cause self-care deficits in the person and that are the responsibility of the nurse, although it is necessary to take into account that the fact that the nurse is the reference professional in a nursing diagnosis does not mean This means that other health professionals cannot intervene in the process. There are 5 types of Nursing diagnoses: Real, risk, possible, well-being and syndrome.
3. PLANNING PHASE
Planning consists of the development of strategies designed to reinforce the responses of the healthy client or to avoid, reduce or correct the responses of the sick client, identified in the Nursing diagnosis. This phase begins after the diagnosis is formulated and concludes with the actual documentation of the care plan. It consists of four stages:
- Establishment of priorities, based on Kalish’s or Maslow’s hierarchy.
- Elaboration of objectives.
- Development of nursing interventions.
- Plan documentation.
The Nursing Care Plan is an instrument to document and communicate the patient/client’s situation, the expected results, the strategies, indications, interventions and the evaluation of all of this. There are different types of care plans, among them the following stand out:
Individualized: Allows you to document the patient’s problems, the objectives of the care plan and the nursing actions for a specific patient. It takes longer to prepare.
Standardized: According to Mayers, “it is a specific care protocol, appropriate for those patients who suffer from normal or foreseeable problems related to the specific diagnosis or disease.”
Standardized with modifications: Allows individualization by leaving open options in the patient’s problems, care plan goals, and nursing actions.
Computerized: They require prior capture in a computer system of the different types of standardized care plans; they are useful if they allow individualization for a specific patient.
4. EXECUTION PHASE
In this phase, the nursing plan described above is executed, carrying out the interventions defined in the diagnosis process. Implementation methods should be recorded in an explicit, tangible format in a way that the patient could understand if they wanted to read it. Clarity is essential as it will help communication between those who are assigned to carry out Nursing Care.
5. EVALUATION PHASE
The purpose of this stage is to evaluate progress toward the goals identified in the previous stages. If progress toward the goal is slow, or if regression has occurred, the nursing professional should change the care plan accordingly. Instead, if the goal has been achieved, then care can cease. New problems may be identified at this stage, and the process will restart again. It is part of this stage that measurable goals must be established; failure to establish measurable goals will result in poor evaluations.
The entire process is recorded or documented in an agreed format in the nursing care plan to allow all members of the nursing team to carry out the agreed care and make additions or changes.