Five Stages of Nursing Care Plan
The process of nursing care is a process that consists of five stages:
Assessment is the collection of data relating to the patient in a complete and systematic, were reviewed and analyzed, so that the medical and nursing problems facing patients, whether physical, mental, social, and spiritual can be determined. The assessment includes data collected through interviews, the collection of medical history, physical examination, and laboratory diagnostics.
2. Nursing Diagnosis
Nursing diagnosis is the analysis of the data collected to identify, focus on and address the specific needs of patients as well as a response to actual problems and high risk.
Types of Nursing Diagnosis NANDA there are three, namely:
- Actual Nursing Diagnosis is the human response to current health conditions or life processes are supported by a group of the defining characteristics (signs and symptoms) and related factors including (etiology), which has a contribution to the development or maintenance of health.
- Risk Nursing Diagnosis was demonstrated human response that can arise in person or vulnerable groups and supported by risk factors that contributes to the increased susceptibility.
- Wellness Nursing Diagnosis is outlining the human response to the health of individuals or groups that have a high potential for improving health status.
Components of Nursing Diagnosis Statement is:
- Problem (problem or need) is the name or label diagnoses identified from the list of NANDA.
- Risk factor / factors related to the cause or suspected cause of the responses that have been identified from the assessment.
- The definition of the characteristics (signs and symptoms):
manifestations were identified in the assessments that support nursing diagnoses.
There are two planning processes:
1. The objectives and desired outcomes of patients to improve health problems or needs that have been assessed, the expected results should be specific, realistic, measurable, shows a definite time frame.
The purpose of nursing is made in accordance with the problems that arise.
The purpose is divided into two, namely:
- The long term goal is a goal is not achieved before discharge but requires constant attention from the patient and / or others.
- Short term goals are goals that usually must be attained before repatriation or transfer to a less acute level of care.
Goals set should lead on the issue, whether to prevent, reduce or eliminate them.
2. Appropriate nursing interventions to assist patients in achieving the expected results.
Implementation is the management and realization of the plan that had been developed in the nursing pe stage.
At the time the action will be implemented nursing, nurses perform a contract with the client to explain what will be done and the expected role of the client.
The evaluation is to determine the patient’s progress towards the achievement of expected results and patient response to the effectiveness of nursing interventions. Then change the treatment plan if necessary.
The five stages are interrelated and can not be separated. These stages together in a circle of thought and action continuous.