The nursing process is the cornerstone of the nursing practice. Whether you’re a student nurse or an experienced nurse, you should always remember and practice the nursing process by heart. It’s a fundamental approach to providing excellent patient care, making sure you give your patients the finest results possible. The five steps of the nursing process will be covered in full in this article, along with helpful implementation advice.
The Purposes of the Nursing Process
The nursing process serves the following key purposes:
- Identifying Health Status and Needs
The nursing process is used to assess the client’s current health status and identify any actual or potential healthcare problems or needs.
- Establishing Care Plans
In doing the nursing process, you develop plans to address the identified healthcare needs and concerns.
- Delivering Targeted Interventions
The nursing process provides specific nursing interventions to meet the client’s identified needs.
- Promoting Health and Evidence-Based Care
The nursing process also supports evidence-based care. Applying the best available evidence to support nursing care and promote positive human functions and responses to health and illness.
- Legal Protection
The nurses are being protected from legal issues related to nursing care when the nursing process is followed correctly.
- Systematic Organization
The nursing process serves as a guide for nurses to perform their practice in a systematically organized way.
- Establishing a Health Database
Through the nursing process, the nurse can create a comprehensive database about the client’s health status, concerns, response to illness, and ability to manage their health care needs.
Overall, the nursing process is a crucial framework that guides nurses in providing high-quality, evidence-based, and personalized care to their clients.
What is the Nursing Process?
The nursing process is a problem-solving approach that involves assessing, diagnosing, planning, implementing, and evaluating patient care. It’s a cyclical process, meaning that each stage builds upon the previous one, and it’s essential to revisit earlier stages as needed. This process is used in various healthcare settings, from hospitals to community health organizations, and applies to patients of all ages and conditions.
The 5 Steps of Nursing Process
- Assessment– This is the first step in the nursing process and is called data collection. Assessment is both the most basic and the most complex nursing skill, which is at the same time both the initial step in the nursing process and an ongoing component in every other step in the process. To assess well, the five senses and physical inspection techniques such as inspection, palpation, percussion, and auscultation are being utilized to identify abnormalities or changes in status and for the nurse to intervene appropriately.
Data collection is composed of observation of the patient, patient interview, family and support systems, examination of the patient, and the review of medical records. Culture consideration is given an important venue while assessing a patient and one essential skill of assessment is the ability of the nurse to collect only relevant data. In assessment, family relationships, support systems, food preferences, lifestyle habits and activities of daily living, communication styles, and health care beliefs are all included as aspects.
Frameworks used as guidelines in the assessment are Maslow’s theory of basic needs, Henderson’s components of nursing care, Gordon’s functional health needs, NANDA’s human response patterns, Nursing theories, and human growth and development.
Nursing observations result in objective data. Objective data are factual data that are observed by the nurse. The nurse describes the signs or behaviors observed without drawing conclusions or making interpretations. Data that consists of information given verbally by the patient is called subjective data. Examples of objective and subjective data are:
Objective data: Tremors of both hands, hair combed, makeup applied, Urinated to approximately 300 cc dark amber urine
Subjective data: “I want to be alone.”, “I feel very nervous about the surgery.”, “This catheter is killing me.”
An interview is a structured form of communication utilized by a nurse to collect data. The use of therapeutic communication like open-ended questions is very beneficial to elicit a comprehensive image of the health pattern.
A complete examination of the patient is another integral aspect of the assessment. The body system approach and the cephalocaudal (head-to-toe) approach are mainly used for the examination to be methodical and also to avoid omissions. An examination is composed of visualization, auscultation, percussion, also the five vital signs (temperature, pulse, respiration, blood pressure, and pain.
- Diagnosis– It is the second step in the nursing process, and it is the phase by which the nurse analyzes the data gathered and identifies the problem for the patient. It is the process of data analysis, problem identification, and the formulation of nursing diagnosis.
A nursing diagnosis is a clinical judgment about the patient’s response to actual or potential health conditions or needs. Similar to medical diagnoses, they are governed and adhere to an international, uniform framework. In order to provide a standard reference for all nurses to follow when developing their nursing diagnoses for patients, the North American Nursing Diagnosis Association (NANDA) creates definitions and terminology related to nursing diagnosis.
Formulating a nursing diagnosis follows this format: P-E-S (Problem + Etiology + Symptoms.), although not all types of nursing diagnoses because the risk nursing diagnosis does not include symptoms since there is just a possibility of an occurrence. The three types of nursing diagnoses are actual, risk, and possible nursing diagnoses. When writing the nursing diagnosis, the nurse usually uses the words “related to,” abbreviated as “r/t”? Examples of diagnosis are:
Actual nursing diagnosis: Impaired skin integrity r/t physical immobilization as manifested by disruption of the skin surface over the elbows and coccyx
Risk nursing diagnosis: Risk for impaired skin integrity r/t physical immobilization in a total body cast.
Possible nursing diagnosis: Possible nutritional deficit (It is an incomplete problem statement since the validity of the problem is uncertain but considered a possibility based on the patient’s response).
- Planning– This phase is also known as outcome identification. With your diagnoses in hand, the next step would be to develop a plan of care. This involves setting specific, measurable, achievable, relevant, and time-bound (SMART) goals for the patient. As a nurse, you’ll work with the patient and other healthcare professionals to create a plan that addresses the patient’s needs and promotes optimal health outcomes.
Tips for Planning:
Involve the patient and their family in the planning process as much as possible.
Ensure the plan is realistic and achievable.
Prioritize the patient’s needs and focus on the most critical issues first.
The SMART technique, abbreviated as specific, measurable, attainable, realistic, and time-bound, is usually used in making an outcome statement. Meanwhile, an outcome statement is composed of patient behavior, criteria of performance, conditions (if needed), and time frame.
There are two types of goals used in the planning stage: Short-term and Long-term goals. Short-term goals focus on immediate needs and ensure the patient’s skin remains healthy to prevent complications.
Long-term goals aim for the patient to regain independence with daily activities post-discharge and prevent future complications.
Example:
Nursing Diagnosis: Risk for impaired skin integrity related to decreased mobility post-surgery.
Planning:
Short-Term Goals: At the end of 2 days of nursing intervention, the:
- Patient will have intact skin with no redness or irritation by the end of the day.
- Patient will be able to independently turn from side to side in bed by the second-day post-surgery.
- Patient’s pain will be managed to a level of 4 or less on a 0-10 scale using pain medication.
Long-Term Goals: At the end of 4 weeks of nursing interventions, the:
- Patient will be able to ambulate with a walker independently.
- Patient will demonstrate proper wound care techniques to prevent infection.
- Patient will maintain adequate nutritional intake to promote healing.
- Implementation – The implementation stage involves putting the plan of care into action. As a nurse, you’ll carry out the interventions and treatments outlined in the plan, working closely with other healthcare professionals as needed. This stage requires strong communication and organizational skills, as well as the ability to adapt to changing circumstances.
Nursing interventions are considered activities that are planned and implemented to help patients achieve identified outcomes. Nursing interventions are often given nursing rationale to prove that those interventions are based on principles and knowledge integrated from nursing education and experience as well as from behavioral and physical sciences.
Nursing interventions should be safe for the patient, be congruent with other therapies, realistic, and consider meeting the lower level of survival needs before higher-level needs. It is imperative too that nursing interventions meet the patient’s personal goals and values.
Example:
Nursing diagnosis: Knowledge and skill deficit in taking newborn rectal temperature related to first-time parenting as evidenced by verbalization of lack of knowledge (“Hindi ko po alam kung paano kumuha ng temperature ng baby ko” as verbalized by the mother).
Goal and Outcome: After 24 hours of nursing interventions, the patient will learn how to take an accurate rectal temperature of her newborn.
Nursing interventions:
- Discuss when to take baby’s temperature; signs and symptoms indicating illness.
- Demonstrate how to take a rectal temperature on newborn,
- Explain safety precautions and when to notify physician for fever
- Provide reinforced practice in taking her newborn’s temperature
There are several types of nursing interventions. These are the environmental management, independent nursing intervention or one that is nurse-initiated and ordered intervention, the dependent nursing intervention or nurse-initiated and physician-ordered intervention, and the collaborative intervention or intervention applied with the assistance of other health team members, like a dietician, pharmacist, midwife, and others.
- Evaluation– this phase should be done continuously while care is being given and as the nurse evaluates progress from intermediate outcomes up to discharge outcomes. Evaluating is composed of documenting responses to interventions, evaluating the effectiveness of interventions, evaluating outcome achievement, and reviewing the nursing care plan.
When deciding how well an outcome was met, there are three alternatives: met, partially met, and not met. When written, an outcome evaluation statement includes if met, partially met, or not met and actual patient behavior as evidence.
Example:
Nursing diagnosis: Ineffective airway clearance related to bronchial inflammation, edema formation, and sputum production as evidenced by dyspnea and coughing.
Goals and Outcome:
After 8 hours of nursing interventions, the patient will be able to maintain a patent airway by displaying clear breath sounds upon auscultation, no dyspnea, and a normal respiratory rate and oxygenation values.
Nursing Interventions:
Independent:
- Assess the rate and rhythm of respiration and use of accessory muscles.
- Elevate the head of the bed.
Dependent:
- Administered salbutamol via nebulization as ordered.
Evaluation:
After 8 hours of nursing intervention, the patient was able to maintain a patent airway as evidenced by clear breath sounds, a respiratoty rate of 18 cpm, 02 sat of 99%, and absence of dyspnea.
Or you can also write:
Goals and outcomes were met as evidenced by clear breath sounds, a respiratory rate of 18 cpm, 02 sat of 99%, and absence of dyspnea.
If outcomes are not met, the nurse should revise the care plan when appropriate.A review of the nursing care plan is composed of reassessment, review of nursing diagnoses, review of outcomes and replanning, and review of implementation.
Overall, the nursing process is a vital part of nursing practice, providing a framework for delivering high-quality patient care. By following the five stages of the nursing process – assessment, diagnosis, planning, implementation, and evaluation – you’ll be able to provide patient-centered care that addresses the individual’s unique needs. Always remember that a wrong assessment will lead to an ineffective nursing care plan so in the first step, you should be good in conducting the assessment to target the main problems of the patient to address them effectively and to avoid repeating the cycle and delaying the needed care to the patient.
References
- Hughes, Suzanne. (2012). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice. Nurse Education in Practice. 12. e12. 10.1016/j.nepr.2011.09.002.
- NANDA International & Herdman, T. H. (2012). NANDA International Nursing diagnoses: Definitions and classification 2012-14. Wiley-Blackwell.