The standards of practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. This practice includes the areas of assessment, diagnosis, outcome identification, planning, implementation and evaluation. The nursing process includes meaningful actions taken by professional nurses (RNs) and forms the foundation of nurses' decision-making (“American Nurses Association,” 2010). Assessment is the accurate collection of comprehensive data pertinent to the patient's health or situation (American Nurses Association, 2010). Assessment is the first step in the nursing process and the most important. Assessment is the accurate collection of patient health data, including both subjective and objective information. Subjective data includes information that can only be described or verified by the patient. This may include chest pain, headache, or muscle aches. The objective date is data that can be observed and measured. This type of data is obtained using inspection, palpation, percussion, and auscultation during the physical examination. Objective data can also be provided through diagnostic tests. This is important for correct diagnosis, planning and intervention. Examples of this may include vital signs, warm, clammy skin, and coughing with yellow sputum. The second standard in the nursing process is diagnosis. During this phase, the registered nurse analyzes the assessment data to determine the diagnosis or problems ("American Nurses Association," 2010). Analysis involves recognizing signals, sorting and organizing or grouping information, and determining the patient's strengths and unmet needs. These results are compared to the documented norms… halfway through the document… driven by the changing state of the customer throughout the process. The nurse can collaborate with the client, family, significant others, and other members of the health care team in applying the steps of the nursing process. The following standards must be used by a professional nurse, using critical thinking and clinical judgment in applying the nursing process for each client under the care of professional nurses: assessment, analysis and reporting, planning, implementation and evaluation ("Ohio Board of Nursing, " 2008). As a nurse practitioner new to the practice, I try to implement laws and standards of practice into the care of my patients on a daily basis. I try to adhere to the scope of practice, rules and regulations. It is my obligation as a healthcare professional to do what is in the best interest of my patient while adhering to these guidelines.
tags