This essay is about the nursing process, the essay asses knowledge and understanding of patient assessment. In this essay the nursing process and the four stages are described. The essay discusses a nurse assessing a patient through communication and maintaining a safe environment.
The nursing process focuses on the whole person's care; physical, intellectual, emotional and spiritual. This is to make sure that nothing is left out. Kozier, Erb & Berman (2008) say that the nursing process centres on the patient to structure the delivery of the nursing care. The nursing process involves collecting data and analysing the data to work out a patient strengths and if any health problems, producing a plan, reviewing the plan and its agreed outcomes. According to Lippincott, Williams & Wilkins (2008) when the nursing process is followed properly it has many advantages. This offers a structure for applying a nurse's knowledge and skills to set goals in an organised manner.
There are four stages in the nursing process; assess, plan, implement and evaluate.
The first stage is the assess stage. Kozier, Erb, Berman et al (2008) say that assessing is to collect, organise, validate and document the information. Assessing is a process that has to be constantly carried out throughout all the four stages. Information is collected from family, doctors and the patient themselves. This gives a good understanding on the patient strengths, weaknesses, likes or dislikes, allergies and can also let a nurse know what the patient is capable of.
The second stage is the planning stage. Lippincott, Williams & Wilkins (2008) stated that the planning stage is when the nurse and the patient develop a care plan. They say that a care plan should have two parts; a patients outcomes, or expected outcomes, this tells results that have to be achieved by a certain time. This gives the patient long-term and short-term goals which could give a patient motivation; this would then help the patient to achieving the goals. Kozier, Erb, Berman et al (2008) say that the patient input for the care plan is just as important as the nurses to make the care plan effective. A patient should be encouraged to take part actively.
The third stage is Implementation stage; Brooker & Waugh (2007) say this is the stage where the care is delivered to the patient. It is when the care plan is put into action.
The fourth and final stage is the evaluation. Newton (1991) says that it is linked with the planning stage. The goals that are set are reviewed to see what have been achieved, if these goals are achieved the nurse can revaluate and implement new goals for the patient to achieve.
Communication is essential part of nursing. According to Newton (1991) it includes verbal and non-verbal communication. Nursing times (2006) say a nurse should be able to pick up on verbal and non-verbal signs when assessing a patient. When assessing a patient the nurse should avoid the use of medical jargon and speak to patient using words that the patient will understand. Problems that can arise with communication are that patients can have impairments of speech, hearing or sight. Other problems with communication are that there could be cultural or language difficulties, the patient could also suffer from physiological problems. To solve the problems of communication a nurse can use certain communicating aids for example if the patient cannot speak they could be given cards and pictures to show their feelings or what they want.
Kozier, Erb, Berman (2008) state that non- verbal communication can be used with a nurse using four of their five senses, vision, smell, hearing and touch. By using vision a nurse can read a patient's body language for example if a patient is sore the patient could be restless. Smell can be used for body or breath odours. Hearing is used to listen to what the patient is saying. Touch is also used to communicate by helping a patient move around if they have problems walking or seeing.
Randle, Coffey & Bradbury (2009) say that a nurse should be approachable to communicate and is not to come across too busy to the patient or the relatives. A nurse should be aware of their own body language; if they are smiling, have eye contact and nodding at appropriate moments. Randal, Coffey & Bradbury also say a nurse should be cautious when asking questions so they are not intrusive or judgemental towards the patient.
Holland, Jenkins & Solomon et al (2003) believe that every person keeps themselves safe as this is a survival skill that everyone has.
Brooker & Waugh (2007) say that a patient safety is just as important as their health; a part of nursing care is to notice factors that can influence a patient's safety. This could be that a patient might not be able to hold a cup so a nurse would put the patient drink into a beaker. By helping a patient to eat or drink this could provide the patient with energy and nutrients for recovery which therefore can give the patient independence and they might be able to get home sooner.
Holland, Jenkins & Solomon (2003) say that maintaining a safe environment requires consideration of both internal and external environments. Internal environment are the body and brain and the external environment is the surrounding environment.
When assessing a patient on maintain a safe environment Kozier, Erb &Berman et al (2008) suggest that the nurse should risk asses the procedure from sitting to chair by TILE. The nurse should assess if the patient is too tired, if they are in any pain to stand. The nurse should also assess the environment around the patient that there are no lockers or tables in their way. The nurse should also check that the patient has slippers on so that the patient does not slip or fall.
This essay described the nursing process and the four stages; it also assessed knowledge and understanding of patient assessment. This essay discussed assessing communicating by using communication aids. Maintaining a safe environment is just as important as a patient health. A nurse has to think about the internal and external factors when maintaining a safe environment. This is achieved by putting in a holistic approach.
Brooker C, Waugh A (2007) Foundations of nursing practice fundamentals of holistic care. Edinburgh: Elsevier Limited pp321 pp359
Holland K, Jenkins J & Solomon J et al (2003) Applying the Roper, Logan, Tierney model in practice Edinburgh: Elsevier science limited pp43
Kozier B, Erb G, Berman A et al (2008) Fundementals of nursing concepts, process and practice. Essex: Pearson Education pp145 pp148 pp162
Lipincott, Williams & Wilkins (2008) Medical – surgical nursing made incredibly easy. 2nd ed. Philadelphia: Wolters Kluwer pp13-14 pp24
Newton C (1991) The Roper-Logan-Tierney Model in action. Hampshire: The Macmillan press pp20
Nursing Times (2006) Communication skills(Essence of care benchmark) (Online) Available: http://www.nursingtimes.net/whats-new-in-nursing/communication-skills-essence-of-care/ 06/11/2009
Randle, Coffey & Bradburry (2009) Oxford handbook of clinical skills in adult nursing. Oxford: Oxford university press pp18-19.