Nursing Process

PURPOSE:

TThis guide provides the Nursing student with an understanding of basic concepts related to the nursing process.

The nursing process is one of the five integrated processes in the test plan. To achieve mastery in management of nursing care, it is essential for nurses to possess skills in nursing process. This improves care and development of nursing care plans for patients.

 

 

The NURSING PROCESS

Like the steps of a science experiment, the nursing profession uses the steps of the nursing

process to build a care plan. The nursing process is a systematic problem-solving method of

delivering individualized care. The nursing process is essential to the practice of nursing is and it

is threaded throughout the NCLEX examination. Please see an overview of the nursing process

below:

OVERVIEW OF THE NURSING PROCESS

Assessment (DATA COLLECTION)

This is the step of nursing process where we collect information about our clients and a

comprehensive database regarding the client is established.

The data collected may be objective or subjective data. Objective data is said to be the data that

the nurse observes or measures and may be described as signs or symptoms. Assessment data

may be considered the factual data that supports the nursing diagnosis. Components of the

assessment data may include the patient’s medications, environment and lab reports etc. The data collected in assessment is clustered and validated.

DIAGNOSIS

 (Statement describing client’s need or problem identified from analysis of assessment)

The second step of the nursing process is the step of diagnosis. The nursing diagnosis is different

from the medical diagnosis because the nursing diagnosis is a summary of the patients need or a

statement describing the patient’s problem/response to a disease process. When client problems

are identified from the assessment data, the nurse labels the current problems or potential

problems with applicable nursing diagnostic labels from NANDA listings. Nursing diagnoses have

three components and must be supported by the information collected in assessment.

1. NANDA label that describes problem/need

2. Etiology or related to factor associated with problem or identified client needs.

3. Evidence of the client problem/identified need that is supported by assessment and may

be retrieved directly from assessment info. This third component of the nursing diagnostic

statement is usually described “as manifested by” or “as evidenced by”

To complete this step, the nurse should consider what are the patient’s needs/problems?

PLANNING

This is the step of the nursing process where the nurse identifies the client’s needs and develops

criteria for expected client outcomes. This step of the process facilitates prioritization of life

threatening concerns. The nurse develops strategies to correct, reduce or prevent a client

problem. This step involves the plan for achievement of client outcomes, and the nurse actually

records a plan of care. The nurse develops interventions, creates the care plan and develops

goals to identify and communicate the nursing actions to be done. Goals for clients should be

specific, measurable, attainable, relevant/realistic and have a time component for expected

evaluation for the goal. They must all be client centered/sometimes client and family centered and

singular.

IMPLEMENTATION

This is the step of the nursing process that encompasses client advocacy including client

teaching, delegating, supervising, and evaluating the work of others. The step of implementation

includes initiation and completion of interventions, collaboration/delegation and the documentation

of the plan of care. Prior to completion of nursing actions, the nurse should utilize good judgment,

decision making and re-assessment. During this step the nurse completes the nursing actions

identified in the planning phase of the process.

EVALUATION

Evaluation is usually continuous throughout the nursing process. During this step, the nurse

decides if the nursing interventions were effective or helpful in meeting the desired client

outcomes. Evaluation of client goals is done to determine if goals were achieved. A decision is

made to discontinue, continue or revise the current plan. The nurse uses the step of evaluation to

make clinical decisions or to redirect client care.

Teaching/Learning

The nurse assists patients with the acquisition of knowledge, skills and attitudes that will

promote changes in behavior.

Culture and Spirituality

Understanding Cultural diversity and spirituality in nursing does not mean knowing everything

about every cultural group worked with or that exists. It does mean, however, that the nurse is

aware of factors such as orientation to time, space and any gender-specific preferences, country

of origin, language preference, age, communication style, views on health, food preferences,

religion, family and community relationships. The nurse learns this from patients by asking

appropriate questions. The goal is to deliver more efficient care while improving the client’s

response to treatment modalities. If deemed safe by the health team, the patient is usually

allowed to partake in cultural and spiritual activities.