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
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.
(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?
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
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 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.
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.