The Nursing and Midwifery Council (NMC, 2008) highlight that the care of patients must be a priority and to treat them as individuals. In order to achieve this nurses must use a systematic technique known as the nursing process when planning and delivering care. It originated in the USA and was introduced the UK in the 1970's in an attempt to move nursing away from traditional and task oriented care, to more evidence based and holistic approach to care (Castledine, 2011). It was clearly defined in 1967 when Yura and Walsh published a book called The Nursing Process, which identified 4 strategic stages that nursing care, should follow (Roper at al 2000). These are assessment; planning: intervention and evaluation, each of these stages will
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In some cases the assessment process may only include a general assessment which involves getting the patients' medical history/condition, next of kin, and so on. This can be done both objectively, through measurement (vital signs) or subjectively through verification from the patient, such level of pain (Castledine, 2011). However sometimes information gathered in the general assessment will lead to a more specialist assessment, for example if a person is not very mobile they may be at risk of developing pressure sores. Therefore the patient needs to be further assessed to decide what their individual care needs are (Nazarko, 2007). The information gathered in the assessment is documented and used to plan the care of the individual with their needs and preferences at the forefront of the care plan.
Planning is the second stage in the nursing process. The main objective of having individualised plans is to help and assist the client, nurse and whole multidisciplinary team in identifying and prioritising interventions that may prevent, reduce or resolve the patients' problems (Leach, 2008). It can prevent potential problems from becoming real ones and solve actual problems, as well as aiming to prevent the problem from recurring again. Planning can be split into a 2 step approach, the first being setting goals and the second identifying actions to achieve these goals. Before goals are set the nurse must first decide what problems are priority but at the same time taking