NURSING PROCESS

Nursing process (NP) is a systematic method which utilizes scientific reasoning, problem-solving and
critical thinking to direct nurses in caring for patients effectively

The nursing process is a systematic problem-solving approach used to identify, prevent and treat actual
or potential health problems and promote wellness.

It has five steps; Assessment, Diagnosis, planning, implementation and evaluation

The nursing process was initially an adapted form of problem-solving technique based on theory used by
nurses every day to help patients improve their health and assist doctors in treating patients.

Its primary aim is to know the health status and the problems of clients which may be actual or
potential. It is made up of a series of stages that are used to achieve the objective—the health
improvement of the patient.

The use of nursing process can stop at any stage as deemed necessary or can be repeated as needed.
This process is inclusive of physical health as well as the emotional aspects of patient health.

Nursing knowledge is used throughout the process to formulate changes in approach to the patient’s
changing condition

Many nurse researchers and theorists are in agreement that nursing process is a scientific method for
delivering holistic and quality nursing care.

Therefore, its effective implementation is critical for improved quality of nursing care.

When the quality of nursing care is improved, visibility of nurses’ contribution to patient’s health
outcomes becomes distinct. In this way, nurses can justify the claim that nursing is a science and an
independent profession

As a nurse, your primary duty is ensuring your patients receive safe delivery of care as outlined by the
plan of care created by the medical team

By following the nursing process, you’ll take a systematic approach to manage your patients’ needs. The
nursing process provides a framework of practice for the nurse to follow to guarantee that the patient
has their needs met
5 subsequent nursing process

Assessment

Assessment is the first step and involves critical thinking skills and data collection; subjective and
objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is
measurable, tangible data such as vital signs, intake and output, and height and weight.

Data may come from the patient directly or from primary caregivers who may or may not be direct
relation family members. Friends can play a role in data collection. Electronic health records may
populate data in and assist in assessment.

An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in
delivering nursing care. Assessment includes not only physiological data, but also psychological,
sociocultural, spiritual, economic, and life-style factors as well.

For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes
and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat,
withdrawal from family members, anger directed at hospital staff, fear, or request for more pain
mediation.

Diagnosis

The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and
implementation of patient care.

Creating nursing diagnoses based on the information you have about this patient will help anticipate any
challenges you’ll need to address on your shift.

A nursing diagnosis should be more focused on addressing the problems your patient

The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential
health conditions or needs.

The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems
such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause
complications—for example, respiratory infection is a potential hazard to an immobilized patient. The
diagnosis is the basis for the nurse’s care plan.
planning

The planning stage is where goals and outcomes are formulated that directly impact patient care based
on EDP guidelines.

These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing
care plans are essential in this phase of goal setting.

Care plans provide a course of direction for personalized care tailored to an individual's unique needs.
Overall condition and comorbid conditions play a role in the construction of a care plan.

Care plans enhance communication, documentation, reimbursement, and continuity of care across the
healthcare continuum.

Goals should be:

 Specific
 Measurable or Meaningful
 Attainable or Action-Oriented
 Realistic or Results-Oriented
 Timely or Time-Oriented

The planning phase is also referred to as the outcomes phase and it is the stage that helps the nurse
start formulating a plan of action.

Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range
goals for this patient that might include moving from bed to chair at least three times per day;
maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through
counseling, or managing pain through adequate medication.

Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as
other health professionals caring for the patient have access to it.

Developing a Nursing Care Plan

A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes
potential needs or risks. Care plans provide communication among nurses, their patients, and other
healthcare providers to achieve health care outcomes. Without the nursing care planning process, the
quality and consistency of patient care would be lost.
Implementation

Nursing care is implemented according to the care plan, so continuity of care for the patient during
hospitalization and in preparation for discharge needs to be assured. Care is documented in the
patient’s record.

Implementation is the step which involves action or doing and the actual carrying out of nursing
interventions outlined in the plan of care.

This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect
care, medication administration, standard treatment protocols and EDP standards.

Nursing care is implemented according to the care plan, so continuity of care for the patient during
hospitalization and in preparation for discharge needs to be assured. Care is documented in the
patient’s record.

As the nurse, what are the action items you will take to see that these goals are met? During the
implementation phase, you’ll create a few nursing interventions to help achieve the patient’s goals.

Actualization or carrying out of the plan of care through nursing interventions

Evaluation

This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare
provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome
has been met. Reassessment may frequently be needed depending upon overall patient condition. The
plan of care may be adapted based on new assessment data

Determination of the patient’s responses to the nursing interventions and the extent to which the
outcomes have been achieved.

Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and
the care plan modified as needed.

During the evaluation phase, the nurse will determine how to measure the success of the goals and
interventions.