The nursing process is a scientific process, which is a foundation, the essential tool, and the enduring skill that has characterized nursing from the beginning of the profession. It has changed and evolved through the years, developing in clarity and scope. It is a plan of care for the patient which may look different from institution to institution but provides both systematic and effective course of intervention to patients. The 6 steps of Nursing Process1. Assessment – It is also 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. In order to assess well, the five senses are being utilized to identify changes in status and in order 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 its 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. While data that is 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 in order 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. 2. 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. There are three types of nursing diagnoses: 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 At-risk or high-risk nursing diagnosis: Risk for impaired skin integrity r/t physical immobilization in a total body cast, diaphoresis 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). 3. Outcome Identification – The nurse develops outcomes for the patient to show an optimum or improved level of functioning in the problem areas identified in the nursing diagnoses. It is developed to make the nursing care both individualized for the patient and realistic for the hospital or home care setting. It is composed of setting priorities and establishing outcomes. 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. Examples of an outcome statement:
4. Planning – The nurse develops a plan of care that prescribes interventions to attain expected outcomes. 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. Outcome: Take an accurate rectal temperature on her newborn before discharge on 04/17/12. Nursing interventions:
There are several types of nursing interventions. These are the environmental management, independent nursing intervention or the 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. 5. Implementation – It is the fifth phase in the nursing process and is consists of validating the care plan, documenting the care plan, giving and documenting the nursing care, and continuing data collection. It is primarily focused on working with the patient and the family to carry out the plan of care. This is done not only to know how the patient responds to the nursing interventions but also to provide increased information for revising the care plan as the status of the patient changes. The patient is an active participant in care as they are given the right to refuse or request interventions. On the other hand, the nurse is flexible and should be open to suggestions in changing patient and family priorities, but still committed to help promote health, reduce and eliminate, or prevent problems. 6. Evaluation – It 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: Impaired tissue integrity r/t pressure and poor circulation Outcome statement: 04/17/09 Decubitus ulcer will be healed in 1 month. Outcome evaluation statements: (Done on 05/17/09 or earlier)
Review of the nursing care plan is composed of reassessment, review of nursing diagnoses, review of outcomes and replanning, and review of implementation. Written By: Darby Faubion BSN, RN One of the most important tools a nurse can use in practice is the nursing process. Although nursing schools teach first-year students about the nursing process, some nurses fail to grasp the impact its proper use can have on patient care. In this article, I will share information about the nursing process, its history, its purpose, its main characteristics, and the 5 steps involved in carrying out the nursing process. After reading this article, you will be able to answer the question, “what is the nursing process” and understand what is involved in each of the 5 steps of the nursing process. Additionally, throughout this article, after discussing a step of the nursing process, I will share an example of how the nurse would proceed with that step. For this article’s purposes, we will use information about the following patient: Mr. Collie, a fifty-four-year-old white male being admitted to the Medical-Surgical floor for acute congestive heart failure. The nursing process is a series of steps nurses take to assess patients, plan for and provide patient care, and evaluate the patient’s response to care. It is considered the framework upon which all nursing care is based. The earliest version of the nursing process was introduced in 1955 by Lydia Hall. Ms. Hall identified three steps of the nursing process: observation, administration of care, and validation. Other versions of the nursing process appeared throughout the next decade. Dorothy Johnson, in 1959, described nursing as "fostering the behavioral functioning of the client.” Ms. Johnson’s version of the nursing process included the three steps: assessment, decision, and nursing action. Finally, in 1961, Ida Jean Orlando-Pelletier introduced the version of the nursing process known to nurses today.The nursing process as we know it today is based upon the “Deliberative Nursing Process Theory” developed by Ida Jean Orlando-Pelletier. Ms. Orlando-Pelletier's version of the nursing process includes five steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation. The purpose of the nursing process is to establish a standard of care where nurses assess patients and create plans of action to address individualized patient needs. The nursing process has other purposes, as well, including but not limited to the following. • Establishes plans to meet patient needs • Guides nurses in the delivery of high-quality evidence-based care • Protects nurses against potential legal problems • Promotes a systematic approach to patient care that all members of the nursing team can follow There are several characteristics associated with providing nursing care. The following is a list of the seven main characteristics of the nursing process and an explanation for each one. Perhaps the most essential characteristic of the nursing process is that it should be used within the nurse’s legal Scope of Practice. Effective use of the nursing process requires the nurse to utilize nursing knowledge and skills to identify and resolve problems. Nurses should develop and continuously strengthen critical thinking skills and the use of evidence-based nursing interventions. A well-thought-out approach to patient care leads to organized, systemic patient care that is delivered efficiently and in order. It is imperative that nurses understand the importance of client-centered nursing care. The nursing process characteristic of client-centered care helps nurses plan care that is individualized to the patient. It also supports patient autonomy, which is every patient’s right. As the title suggests, goal-directed care is a form of nursing care delivery based on achieving individualized goals to achieve desired patient outcomes. Goals are created through the collaborative efforts of nurses, other members of the healthcare team, and patients. When planning patient care, it is necessary to identify all health issues and risk factors and prioritize patient care, focusing on the most serious issues first. As you learn about the nursing process steps later in this article, it will become evident that the process is continuous, and nurses must repeat steps. As continued assessments and evaluations occur, and depending on the patient’s response to care, the order of priorities in the care plan may change. The nursing process is a dynamic process as it is constantly affected by the patient's needs, circumstances impacting their needs, and the environment in which care is applied. It encompasses emotional, physical, social, and medical aspects. Each phase of the nursing process interacts with and is influenced by other phases in a cycle of activity. From the time of admission until the patient is discharged from care, the dynamics of the cycle of nursing care continues. The nursing process consists of five steps which encompass the care provided. The five nursing process steps are: 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation The following are explanations for each step of the five steps of the nursing process, information about why each is important, the main objectives of each step, the skills needed to complete each step, challenges nurses may face in each step, and a real-life example for each step.
• The Journal of Professional Nursing publishes articles focused on baccalaureate and higher degree nursing education, research, education and practice partnerships, and policy related to nursing education, including topics related to the nursing process. • BMJ Journals- Evidence-Based Nursing researches international healthcare journals and implements measures to validate research and its relevance to nursing practice. ABN then publishes commentaries and summaries from the findings to educate nurses. • The American Nurses Association is a professional organization established to advance and protect the profession of nursing. The ANA represents the four million registered nurses in the United States. The Association’s website offers many resources for nurses, including this article about the Nursing Process.• Study.com is an online education resource to help individuals prepare for tests and offers opportunities to earn credits toward college degrees. The website offers several topics of interest for nurses and nursing students, including content about the nursing process. One lesson offered on the website is Nursing Process: Purpose and Steps. • NursingCE is an online resource to help nurses meet licensing and continuing education requirements. The website offers access to its blog which features articles like A Guide to the Nursing Care Process written by Kathy Quan RN, BSN, PHN. • The Nursing Process (ADPIE)- This video presented by That Nursing Prof, features a breakdown of the nursing process, explaining why it is essential for all nursing care and how it contributes to making the nursing profession unique.• The Nursing Process- Featured on Nursing School Explained’s YouTube channel, this video explains the nursing process as the foundation of all nursing practice. It explains each phase of the nursing process in a little more than fourteen minutes. • Mastering the Nursing Process (Top Tips)- NursingSOS breaks down the nursing process step-by-step in this video. The host offers her top tips on how to master using the nursing process in daily practice. • Nursing with Dr. Hobbick: Dr. Stacey Hobbick is a nurse and nurse educator who shares her perspective on important nursing topics, including the Nursing Process.• Nursing Mnemonics Show teaches about one nursing mnemonic in each of its three- to five-minute episodes, including Episode 22, Steps in the Nursing Process. • The Nursing Podcast: Jon Haws, RN, is the host of Nursing Podcast, a Critical Care Nurse, Nursing School Mentor, and NCLEX Educator. His podcast features information relevant to new and experienced nurses alike, like the content found in the episode Learn the Nursing Process and ADPIE. • Understanding the Nursing Process in a Changing Care Environment: Authors Mary Murray and Leslie Atkinson break the nursing process into organized steps to help readers comprehend. The newest edition of the book includes considerations for today's ever-evolving healthcare system and addresses issues such as cultural diversity, managed care, home health care, and illness prevention.• Understanding the Nursing Process: This book guides student nurses and nurses wishing to improve the use of the nursing process, on measures to use the nursing process, concept mapping, and care planning. The authors offer need-to-know concepts and easy-to-understand learning activities and case studies. • Applying the Nursing Process- The Foundation for Clinical Reasoning: In this book, readers find guidance to help them understand and apply each step of the nursing process, with emphasis on developing critical thinking and clinical reasoning skills. The author offers strategies, tools, and examples to help nurses develop the skills needed to succeed in nursing. Throughout this article, you learned the answer to the question, “what is the nursing process and what are the 5 steps of the nursing process?” Nurses who learn about the 5 steps involved in carrying out the nursing process and use them in daily practice help establish strong nursing practices and contribute to improved patient outcomes. As a nurse educator, I encourage you to familiarize yourself with each step of the nursing process and integrate its principles as you provide patient care.While there are similarities in the methods, the approach to identifying problems, gathering information, and finding solutions differ between the nursing process and the scientific method. For example, in the scientific method, the first step is to question or identify a problem and then gather data. The first step in the nursing process is to gather data by performing an assessment. Then, the problem, also called the nursing diagnosis, is identified. The nursing process is an effective way to put nursing knowledge into clinical practice and provide quality patient care. Because it is so effective, all nurses should utilize the nursing process in daily practice. Unfortunately, for various reasons, some nurses may not use the nursing process. As a former nursing instructor, I cannot stress the importance of using the nursing process enough. It provides an excellent guide for carrying out patient care and evaluating effectiveness of care. Doctors do not use the nursing process. Physicians use a diagnostic approach to patient care. Their process of caring for patients involves focus on cause and effect of an illness or disease and emphasis on treating symptoms and restoring the patient to health. However, every member of the healthcare team is (or should be) aware of what the nursing process is and why it is important in patient care. ADPIE is the acronym used to represent the five nursing process steps. It stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation. It is important for nurses to follow all the steps of the nursing process. In fact, the American Nurses Association’s Scopes and Standards of Practice describe a level of competent nursing care demonstrated through use of the nursing process. According to the ANA, the nursing process is “the essential core of practice for the registered nurse to deliver holistic, patient-focused care.” Critical thinking helps nurses define patient problems and make intelligent, deliberate decisions about care planning and implementing care. Critical thinking is an essential skill for carrying out the nursing process because it helps nurses solve problems by gathering information and considering possible solutions before implementing an action plan. Health information systems are systems that integrate data collection, processing, reporting, and the use of information to improve care delivery. Health information systems can increase efficiency and accuracy in all steps of the nursing process. Some software programs prompt nurses to ask specific questions, or if a value that is out of the acceptable range is entered, the system will flag the entry, so the nurse knows to verify the value. Most current systems have standard nursing diagnoses associated with symptoms as references. Once a nursing diagnosis is identified, those systems can quickly access information related to that diagnosis. The health information system also makes it possible to compare large amounts of data at once and identify achievable patient outcomes and estimate time frames for reaching goals. Maslow's Hierarchy of Needs Theory consists of five levels to prioritize care: basic physiological needs, safety and security, love and belonging, self-esteem, and self-actualization. Nurses can use the concepts of Maslow's theory in nursing practice to help prioritize care of multiple patients. Using Maslow’s theory, nurses prioritize which patients to see first and then prioritize the care provided based upon the Hierarchy of Neeeds Model. The following are the levels of Maslow’s theory and examples of how the nurse may use them in the nursing process. • Basic Physiological Needs: The nurse should ensure basic needs such as food, water, and elimination are met. Observing for respiratory and cardiac symptoms is included in this level. • Safety and Security: Observe the patient's room/environment for safety risks. For example, a home health nurse would educate patients to remove throw rugs which could cause slips and falls. • Love and Belonging: The nurse should build rapport with the patient and any family member/caregiver. Family support should be encouraged if the family’s presence is positive and does not cause the patient undue stress. • Self-esteem: To use this level of Maslow’s Hierarchy of Needs Theory in the nursing process, the nurse can encourage the patient’s success and speak positively about their efforts. • Self-actualization: Focus on short-term, then long-term goals, rehabilitation and return to home. The implementation phase of the nursing process steps may include some tasks that can be delegated. Delegation involves the assignment of specific tasks or activities related to patient care to another person. For example, the registered nurse may assign the licensed vocational/practical nurse or nursing assistant specific jobs. The assignment must be delegated to someone capable of accepting the task and the delegator retains accountability for the task's outcome. Registered nurses may not delegate tasks related to making nursing judgments to unlicensed assistive personnel. While LPN/LVNs do perform patient assessments, the initial nursing assessment and any assessment performed before changing a nursing care plan must be performed by the registered nurse. The assessment and evaluation phases of the nursing process steps may not be delegated to unlicensed assistive personnel at all. The nursing process applies to pharmacology because it serves as a guide to creating an individualized medication therapy plan unique to the patient. During the planning stage of the nursing process, pharmacological interventions are addressed including defining goals, setting priorities for treatment, identifying pharmacological interventions, and establishing criteria for evaluating effectiveness. Darby Faubion BSN, RN Darby Faubion is a nurse and Allied Health educator with over twenty years of experience. She has assisted in developing curriculum for nursing programs and has instructed students at both community college and university levels. Because of her love of nursing education, Darby became a test-taking strategist and NCLEX prep coach and assists nursing graduates across the United States who are preparing to take the National Council Licensure Examination (NCLEX). |