The Nursing Process
What Is the Nursing Process?
The nursing process is defined as a systematic, logical method of planning that guides all nursing actions in the delivery of holistic, patient-centered care. The nursing process is a type of scientific reasoning that requires critical thinking on the part of the nurse in order to provide the best possible care to the client.
What is the nursing process all about?
The nursing process serves the following purposes:
Identifying the client’s current or potential health care problems or needs (through assessment).
To develop plans to address the identified needs.
To meet those needs, specific nursing interventions must be provided.
To use the best available evidence for caregiving and to promote human functions and responses to health and illness (ANA, 2010).
To protect nurses from legal issues related to nursing care when the nursing process standards are followed correctly.
To assist the nurse in carrying out their practice in a systematic and organized manner.
To create a database containing information about the client’s health status, health concerns, illness response, and ability to manage health care needs.
Nursing Process Characteristics
The nursing process has the following distinguishing features:
Patient-centered. The nursing process’s distinct approach necessitates care that is respectful of and responsive to the individual patient’s needs, preferences, and values. As a patient advocate, the nurse protects the patient’s right to make informed decisions and promotes patient-centered engagement in the health care setting.
Interpersonal. The nursing process serves as the foundation for the therapeutic process, in which the nurse and patient respect each other as individuals, learning and growing as a result of their interaction. It entails a collaborative effort between the nurse and the patient to achieve a common goal.
Collaborative. To achieve quality patient care, the nursing process works effectively in nursing and inter-professional teams, promoting open communication, mutual respect, and shared decision-making.
Dynamic and cyclical.The nursing process is dynamic and cyclical, with each phase interacting with and being influenced by the others.
Critical thinking is required. Critical thinking is required for nurses in identifying client problems and implementing interventions to promote effective care outcomes when using the nursing process.
Steps in the Nursing Process
Assessment, diagnosis, planning, implementation, and evaluation are the five steps in the nursing process. The acronym ADPIE is a simple way to remember the nursing process’s components. Nurses must be taught how to apply the process step by step. They learn how to move back and forth between the steps of the nursing process as their critical thinking develops through experience.
Nursing steps are not distinct entities, but rather overlapping, ongoing subprocesses. Aside from understanding nursing diagnoses and their definitions, the nurse raises awareness of the defining characteristics and behaviors of the diagnoses, related factors to the chosen nursing diagnoses, and interventions for treating the diagnoses.
The following are the steps in the nursing process:
1. “What information is gathered?” ”
Assessment is the first step in the nursing process. It entails gathering, organizing, validating, and documenting information about the clients’ health status. This information can be obtained in a number of ways. When a nurse first meets a patient, she is expected to assess the patient’s health problems, as well as the patient’s physiological, psychological, and emotional state, and to create a database about the client’s response to health concerns or illness, as well as the ability to manage health care needs. Critical thinking skills are required for assessment, necessitating concept-based curriculum changes.
The process of gathering information about a client’s health status is known as data collection. To avoid omitting critical information about the client, the data collection process must be systematic and continuous.
Data collected about a client is generally classified as objective or subjective, but data can also be verbal or nonverbal.
Objective Information or Signs
Vital signs, intake and output, height and weight, body temperature, pulse and respiratory rates, blood pressure, vomiting, distended abdomen, presence of edema, lung sounds, crying, skin color, and presence of diaphoresis are all examples of objective data.
Subjective Information or Symptoms
Subjective data include covert information such as feelings, perceptions, thoughts, sensations, or concerns shared by the patient and can only be verified by the patient, such as nausea, pain, numbness, pruritus, attitudes, beliefs, values, and perceptions of health concerns and life events.
Data from Conversation
Verbal data are statements made by the client or a secondary source that are spoken or written. To assess difficulties such as slurring, tone of voice, assertiveness, anxiety, difficulty finding the desired word, and flight of ideas, the nurse must use her listening skills.
Body language, general appearance, facial expressions, gestures, eye contact, proxemics (distance), body language, touch, posture, and clothing are examples of nonverbal data. Because the client’s body language may not be congruent with what they truly think or feel, nonverbal data can be more powerful than verbal data. Obtaining and analyzing nonverbal data can help to reinforce other types of data and better understand how the patient feels.
Sources of Information
Data sources can be primary, secondary, or tertiary. The primary source of data is the client, while secondary sources include family members, support people, records and reports, other health professionals, laboratory and diagnostics.
The Original Source
The only primary source of data and the only person who can provide subjective data is the client. Everything the client says or reports to the members of the healthcare team is primary.
Secondary data is information that comes from someone other than the client but falls within the client’s frame of reference. If the client cannot speak for themselves, lacks facts and understanding, or is a child, information provided by the client’s family or significant others is considered secondary data. Secondary data sources include the client’s records and assessment data from other nurses or members of the healthcare team.
Tertiary data sources are those that are outside of the client’s frame of reference. Tertiary data sources include textbooks, medical and nursing journals, drug handbooks, surveys, and policy and procedure manuals.
Data Collection Methods
Health interviews, physical examinations, and observation are the primary data collection methods.
An interview is the most common method for gathering important information. An interview is a planned communication or conversation with a specific goal in mind, such as obtaining or providing information, identifying problems of mutual concern, evaluating change, teaching, providing support, or providing counseling or therapy. The nursing health history, which is part of the nursing admission assessment, is one example of an interview. Because patient interaction is typically the most intense during the assessment phase of the nursing process, rapport must be established during this stage.
Examination of the Physical
Aside from interviews, nurses will perform physical examinations, refer to a patient’s health history, obtain a patient’s family history, and general observation to gather assessment data. Establishing a good physical assessment would result in a more accurate diagnosis, better planning, and better interventions and evaluation later on.
Observation is a type of assessment that relies on the five senses (sight, touch, hearing, smell, and taste) to learn about a client. This information is about the client’s appearance, functioning, primary relationships, and environment. Although nurses primarily observe through sight, other senses are used during careful observations, such as smelling foul odors, hearing or auscultating lung and heart sounds, and feeling the pulse rate and other palpable skin deformations.
Validation is the process of verifying data to ensure its accuracy and veracity. One method of validating observations is “double-checking,” which allows the nurse to complete the following tasks:
Ensures that all assessment information has been double-checked, verified, and is up to date.
During a routine assessment, for example, the nurse obtains a reading of 210/96 mm Hg from a client who has no history of hypertension. To validate the data, the nurse should retake the blood pressure and, if necessary, use another piece of equipment to confirm the measurement or delegate the assessment to someone else.
Ascertain the validity and accuracy of objective and related subjective data.
For example, the client’s perceptions of “feeling hot” must be compared to body temperature measurements.
Ensure that the nurse does not reach a conclusion without sufficient data to back it up.
A nurse believes that tiny purple or bluish-black swollen areas under an older adult client’s tongue are abnormal until she reads about physical changes associated with aging.
Make certain that any ambiguous or hazy statements are clarified.
For example, if an 86-year-old female client who is not a native English speaker says, “I am in pain on and off for 4 weeks,” the nurse will need to confirm her statement by asking, “Can you describe what your pain is like?” What exactly do you mean by “on and off”? ”
Obtain additional information that may have been overlooked.
For example, a 32-year-old client is being asked by the nurse if he is allergic to any prescription or non-prescription medications. What happens if he takes these medications?
Differentiate between cues and inferences.
Cues are subjective or objective data that the nurse can directly observe; that is, what the client says or what the nurse sees, hears, feels, smells, or measures. Inferences, on the other hand, are the nurse’s interpretations or conclusions based on the cues. For example, the nurse may notice that the incision is red, hot, and swollen and conclude that it is infected.
Data can be recorded and sorted once all of the information has been gathered. Excellent record-keeping is essential to ensure that all data collected is documented and explained in a way that is accessible to the entire health care team and can be referred to during evaluation.
2. “What is the problem?” says the doctor. ”
The nursing diagnosis is the second step in the nursing process. The nurse will review all of the information gathered and diagnose the client’s condition and needs. Analyzing data, identifying health problems, risks, and strengths, and developing diagnostic statements about a patient’s potential or actual health problem are all part of the diagnosis process. A single patient may be given more than one diagnosis. Formulating a nursing diagnosis using clinical judgment aids in the planning and delivery of patient care.
“Nursing Diagnosis Guide: Everything You Need To Know To Master Diagnosis” goes into greater detail about the types, components, processes, examples, and writing nursing diagnoses.
3. “How should the problem be managed?” ”
The third step in the nursing process is planning. It serves as a guide for nursing interventions. When the nurse, any supervising medical staff, and the patient agree on a diagnosis, the nurse will plan a treatment plan that takes both short and long-term goals into account. Each problem has a specific, measurable goal for the expected positive outcome.
The planning phase is where goals and outcomes that directly impact patient care are developed using evidence-based practice (EBP) guidelines. These patient-specific goals, and their achievement, help to ensure a positive outcome. Nursing care plans are critical during this stage of goal-setting. Care plans lay out a strategy for personalized care that is tailored to an individual’s specific needs. The overall condition and comorbid conditions are considered when developing a care plan. Across the healthcare continuum, care plans improve communication, documentation, reimbursement, and continuity of care.
Planning begins with the initial client contact and continues until the nurse-client relationship is terminated, preferably when the client is discharged from the health care facility.
The nurse who conducts the admission assessment does the initial planning. Typically, the same nurse would develop the initial comprehensive plan of care.
All nurses who work with the client are responsible for ongoing planning. As a nurse gathers new information and assesses the client’s responses to care, she can further personalize the initial care plan. An ongoing care plan is also implemented at the start of a shift. Continuous planning enables the nurse to:
ascertain whether the client’s health status has changed
set the client’s priorities during the shift
choose which issue to concentrate on during the shift
collaborate with nurses to ensure that multiple issues are addressed at each client contact
Planning for Discharge
The process of anticipating and planning for post-discharge needs is known as discharge planning. Nurses must do the following to ensure continuity of care:
When a client is admitted to any health care setting, begin discharge planning for them.
Involve the client and any family members or support people in the planning process.
Work with other health care professionals as needed to meet biopsychosocial, cultural, and spiritual needs.
Making a Nursing Care Plan
A nursing care plan (NCP) is a formal process that identifies existing needs as well as potential needs or risks. Care plans facilitate communication among nurses, their patients, and other healthcare providers in order to achieve positive health outcomes. Without the nursing care planning process, patient care would suffer in terms of quality and consistency.
Nursing Care Plans (NCP): Ultimate Guide and Database goes into great detail about the planning stage of the nursing process.
4. Implementation: “Putting the strategy into action!” ”
The nurse implements the treatment plan during the implementation phase of the nursing process. It entails action or doing, as well as the actual implementation of nursing interventions outlined in the plan of care. This usually starts with the medical staff performing any necessary medical interventions.
Interventions should be tailored to each patient and focused on achieving specific goals. Monitoring the patient for signs of change or improvement, directly caring for the patient or performing important medical tasks such as medication administration, educating and guiding the patient about further health management, and referring or contacting the patient for a follow-up are all actions associated with a nursing care plan.
The Iowa Intervention Project developed a taxonomy of nursing interventions known as the Nursing Interventions Classification (NIC) taxonomy, in addition to NANDA-efforts I’s to standardize the language for describing problems. To determine which nursing interventions are recommended, the nurse can look up a client’s nursing diagnosis.
System of Nursing Interventions Classification (NIC)
There are over 550 nursing intervention labels available for nurses to use when providing proper care to their patients. According to the Nursing Interventions Classification system, these interventions are classified into seven fields or classes of interventions.
Interventions in Behavioral Nursing
These are interventions intended to assist a patient in changing their behavior. In contrast, patient behavior is the focus of behavioral interventions, and the goal is to change it. Behavioral nursing interventions include the following measures:
Stress reduction and relaxation techniques are encouraged.
Providing assistance in quitting smoking
Engaging the patient in physical activity, such as walking, to reduce anxiety, anger, and hostility.
Interventions in Community Nursing
These are interventions that refer to a community-wide approach to changing health behaviors. Rather than focusing solely on the individual as a change agent, community interventionists acknowledge a variety of other factors that contribute to an individual’s ability to achieve optimal health, such as:
Implementing a program to educate first-time mothers
promoting a healthy diet and physical activity
Launching HIV awareness and violence prevention initiatives
Putting on a fun run to raise funds for breast cancer research
Interventions in Family Nursing
These are interventions that affect the entire family of a patient.
When one family member is diagnosed with a communicable disease, a family-centered approach is used to reduce the risk of illness spreading.
assisting a nursing mother in breastfeeding her new baby
Educating family members about patient care
Nursing Interventions in the Health System
These are interventions designed to keep a medical facility safe for all patients and staff, such as:
Procedures to reduce the risk of infection for patients during hospital stays are outlined below.
Making sure the patient’s environment is safe and comfortable, such as repositioning them in bed to prevent pressure ulcers
Interventions in Physiological Nursing
These are interventions related to a patient’s physical health that ensure any physical needs are met and the patient is in good health. There are two types of nursing interventions: basic and complex.
Basic. Hands-on procedures ranging from feeding to hygiene assistance are examples of basic interventions for the patient’s physical health.
Complex. Some physiological nursing interventions, such as the insertion of an IV line to administer fluids to a dehydrated patient, are more complex.
Nursing Interventions for Safety
These are interventions that keep a patient safe and avoid injuries, such as:
Educating a patient on how to summon help if they are unable to move around safely on their own.
Giving instructions on how to use assistive devices like walkers or canes, or how to take a shower safely.
Nursing Care Implementation Skills
Nurses must have cognitive, interpersonal, and technical skills to successfully implement care plans.
Cognitive Skills, also known as Intellectual Skills, are abilities that involve learning and comprehending fundamental knowledge such as basic sciences, nursing procedures, and their underlying rationale prior to caring for clients. Problem-solving, decision-making, critical thinking, clinical reasoning, and creativity are all examples of cognitive skills.
Interpersonal Skills are the abilities to believe, behave, and relate to others. The effectiveness of a nursing action is typically determined primarily by the nurse’s ability to communicate with the patient and other members of the health care team.
Technical Skills are “hands-on” skills that are used for a specific purpose, such as changing a sterile dressing, administering an injection, manipulating equipment, bandaging, moving, lifting, and repositioning clients. All of these activities necessitate safe and competent execution.
Typically, the implementation process includes the following steps:
1. Reevaluating the client
Before beginning an intervention, the nurse must reassess the client to ensure that the intervention is still required. Even if a written order is on the care plan, the client’s condition may have changed.
2. determining the nurse’s need for help
Non-RN members of the healthcare team may also perform other nursing tasks or activities. Unlicensed assistive personnel (UAP) and caregivers, as well as other licensed healthcare workers such as licensed practical nurses/licensed vocational nurses (LPNs/LVNs), may be members of this team. When implementing a nursing intervention, such as ambulating an unsteady obese client, repositioning a client, or when a nurse is unfamiliar with a particular model of traction equipment, the nurse may require assistance.
3. Putting the nursing interventions into action
Nurses must not only have a solid understanding of the sciences, nursing theory, nursing practice, and the legal parameters of nursing interventions, but they must also have the psychomotor skills to safely carry out procedures. Nurses must describe, explain, and clarify to clients what interventions will be performed, what sensations to expect, what the client is expected to do, and what the expected outcome is. Nurses perform activities that can be independent, dependent, or interdependent when providing care.
Nursing Intervention Types
Nursing interventions are classified into three types based on the role of the healthcare professional who is involved in the patient’s care:
Nursing Interventions on Their Own
A registered nurse can perform independent interventions without the assistance or help of other medical personnel, such as:
routine nursing tasks such as vital sign checks
educating a patient on the significance of their medication so that they can take it as prescribed
Nursing Interventions for Dependent Patients
A nurse cannot begin dependent interventions on her own. Some actions, for example, necessitate the guidance or supervision of a physician or other medical professional, such as:
new medication prescription
putting in and taking out a urinary catheter
Using wound or bladder irrigations
Nursing Interventions That Work Together
A nurse participates in collaborative or interdependent interventions involving team members from various disciplines.
In some cases, such as after surgery, the patient’s recovery plan may include prescription medication from a physician, nursing feeding assistance, and treatment from a physical therapist or occupational therapist.
A patient’s diet may be prescribed by a doctor. Diet counseling is included in the patient’s care plan by the nurse. To further assist the patient, the nurse seeks the assistance of the facility’s dietician.
4. monitoring the delegated care
As needed, delegate specific nursing interventions to other members of the nursing team. Consider the abilities and limitations of the nursing team members and supervise the performance of nursing interventions. Another activity that arises during the nursing process is determining whether delegation is appropriate.
The American Nurses Association and the National Council of State Boards of Nursing (2006) define delegation as “the process for a nurse to direct another person to perform nursing tasks and activities.” It generally refers to the assignment of unlicensed assistive personnel to perform activities or tasks associated with patient care while maintaining accountability for the outcome.
Nonetheless, registered nurses cannot delegate nursing judgment responsibilities. Assessment and evaluation of the impact of interventions on patient care are examples of nursing activities that cannot be delegated to unlicensed assistive personnel.
5. Keeping track of nursing activities
Record precisely and concisely what has been done as well as the patient’s responses to nursing interventions.
5. “Was the plan successful?” ”
The fifth step in the nursing process is evaluating. This final stage of the nursing process is critical to a successful patient outcome. After all nursing intervention actions have been completed, the team can now learn what works and what doesn’t by analyzing what was done previously. When a healthcare provider intervenes or provides care, they must reassess or evaluate to ensure that the desired outcome is met. The three possible patient outcomes are as follows: the patient’s condition improved, the patient’s condition stabilized, and the patient’s condition worsened.
Nursing evaluation consists of the following steps: (1) collecting data, (2) comparing collected data with desired outcomes, (3) analyzing client responses to nursing activities, (4) identifying factors that contributed to the success or failure of the care plan, (5) continuing, modifying, or terminating the nursing care plan, and (6) planning for future nursing care.
1. Data Collection
The nurse collects data in order to draw conclusions about whether or not goals have been met. It is usually necessary to gather both objective and subjective data. To facilitate the next stage of the evaluation process, data must be documented concisely and accurately.
2. Data Comparison with Desired Outcomes
The nursing care plan’s documented goals and objectives become the standards or criteria by which the client’s progress is measured, whether the desired outcome is met, partially met, or not met.
When the client response matches the desired outcome, the goal has been met.
When either a short-term outcome was achieved but the long-term goal was not, or the desired goal was only partially attained, the goal was partially met.
The objective was not met.
3. Examining the Client’s Reaction to Nursing Activities
It is also critical to determine whether the nursing activities had any impact on the outcomes, whether they were successful or not.
4. Identifying the Factors That Influence Success or Failure
More data is needed to determine whether the plan was successful or not. Various factors may contribute to goal achievement. For instance, the client’s family may or may not be supportive, or the client may be unwilling to participate in such activities.
5. Continuation, Modification, or Termination of the Nursing Care Plan
Nursing is a dynamic and cyclical process. If the goals were not met, the nursing process is restarted from the beginning. Depending on the general patient condition, reassessment and modification may be required on a regular basis to keep them current and relevant. Based on new assessment data, the care plan may be modified. Problems may arise or change as a result. As clients complete their objectives, new objectives are established. If goals are not met, nurses must evaluate the reasons for this and recommend revisions to the nursing care plan.
6. Planning for Discharge
The process of transitioning a patient from one level of care to the next is known as discharge planning. Discharge plans are personalized instructions given to clients as they prepare for continued care outside of the healthcare facility or for independent living at home. A discharge plan’s primary goal is to improve the client’s quality of life by ensuring continuity of care in collaboration with the client’s family or other healthcare workers providing ongoing care.
According to the Agency for Healthcare Research and Quality, the following are the key elements of IDEAL discharge planning:
Include the patient and family in the discharge planning process as full partners.
Discuss the following five key areas with the patient and family to prevent problems at home:
Describe your daily life at home.
Examine your medications
Highlight potential issues and warning signs
Explanation of test results
Make follow-up appointments.
Throughout the hospital stay, educate the patient and family in plain language about the patient’s condition, the discharge process, and next steps.
Examine how well doctors and nurses explain the patient’s diagnosis, condition, and next steps in care to the patient and family, as well as how well they use teach back.
Listen to and respect the goals, preferences, observations, and concerns of the patient and family.
A discharge plan includes specific client teaching components with documentation, such as:
Home equipment is required. Coordination of home-based care and special equipment is required.
Dietary requirements or a special diet Talk about what the patient can and cannot eat at home.
Medications to be taken at home. List the patient’s medications and discuss the purpose of each medicine, how much to take, how to take it, and potential side effects.
Resources such as contact numbers and addresses of important people. Make a note of the name and phone number of someone to contact if there is a problem.
Danger signs: emergency response Identify and educate patients and families about potential problems and warning signs.
Activities related to home care. Educate the patient on what activities to do and which to avoid at home.
Summary. Discuss the patient’s condition, the discharge process, and follow-up checkups with the patient and family.