Nursing Knowledge Through Nursing Process

"The nursing process is an organizing framework for professional nursing practice." (Ackley & Ladwig, 2011, p. 2). The nursing process contains five steps which are assessment, diagnosis, planning, implementation, and evaluation. Becoming familiar with the nursing process allows the nurse to apply his or her knowledge and skills in an organized, goal-oriented way (Ralph & Taylor, 2011). To implement the nursing process the nurse must possess and use critical thinking skills (Ackley & Ladwig, 2011). At the diagnosis step in addition to critical thinking skills the nurse must have knowledge of the patient's condition such as symptoms, health and medical history, subjective and objective information, and information obtained from the patient's significant others. This knowledge is gained at the assessment step of the nursing process and is used to develop and support the nursing diagnosis. Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life process. It provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability (Carpenito-Moyet, 2010).

In developing a nursing diagnosis the nurse must be familiar with the North America Nursing Diagnosis Association International (NANDA-I) standards. The nursing diagnosis must contain a nursing diagnosis label from the NANDA-I list that fits with the relevant symptoms and nursing diagnosis definition. A nursing diagnosis may have one, two, or three parts. Wellness diagnoses contain only the NANDA-I label and are considered one-part diagnosis. Two-part diagnosis consist of the NANDA-I label and a related to statement. The three-part diagnosis statement also known as PES (problem, etiology, and symptoms) contains a NANDA-I label, a related to statement, and the relevant symptom. The nursing diagnosis is used in the next step of the nursing process (the planning phase) to develop measurable outcomes (Ackley & Ladwig, 2011).

The steps of the nursing process are the basis of clinical decision-making and support evidence-based practice. "Basing nursing practice on evidence or research is a concept that has been added to the nursing process. This concept is called evidence- based nursing."(Ackley & Ladwig, 2011, p. 2). In addition to critical thinking skills the nurse must now develop clinical inquiry skills using evidence-based practice. To develop an accurate diagnosis it is essential that it is based on searching and evaluating evidence (Ackley & Ladwig, 2011).

References

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9 ed.). St. Louis, MO: Mosby Elsevier.

Carpenito-Moyet, L. J. (2010). Nursing diagnosis: Application