The nursing process refers to the steps nurses take to assess and treat patients, with the goal of helping them get better and then back on their feet again and fully functional in society. Nurses use this method as part of every interaction they have with patients because it gives them the opportunity to gather information about the patient’s condition and then formulate a plan of action to help fix it.
This comprehensive guide to the nursing process will give you a detailed overview of how nurses use this technique every day when interacting with patients and taking care of them.
What Is the Nursing Process?
A nursing process is a holistic approach to patient care that focuses on five major steps: assessment, nursing diagnosis, planning, implementation, and evaluation.
These processes work together to ensure that patients are cared for by considering their physical, psychological, and spiritual health. Although most nurses may not memorize all of these steps during training—and some might never even encounter them in their day-to-day practices—the nursing process still forms a foundation for how patients are treated.
The nursing process can be a little overwhelming, so let’s break it down and give you an idea of how each step works.
What is the purpose of the nursing process?
The nursing process is a way of approaching care that includes four phases: assessment, diagnosis, planning, and implementation. Each phase has its own set of objectives and criteria for accomplishing these goals; following each of these steps helps ensure safe, effective patient care. So what does it mean for each step? Let’s break it down
Characteristics of the nursing process
In a nutshell, you need to have three elements present in order for a nursing process to exist:
- a client or patient with an identified problem;
- nursing diagnosis that identifies what is wrong and explains why it is wrong
- nursing interventions that address the problem.
This is done within an ethical context, in which nurses use evidence-based practice. All of these variables are critical components of professional nursing practice as specified by both federal and state governments.
In a larger sense, nurses use their own judgment to determine when each step should be taken and how best to manage their resources so they can deliver optimal care at all times.
For example, when a nurse determines that pain management strategies are insufficient, she might prescribe additional medication before recommending other strategies such as diet changes or physical therapy.
Nursing Process Steps
- Assessment
- Plan of Care
- Implementation
- Evaluation
- Follow-up
Assessment: “What data is collected?”
Determine what aspects of your patients’ condition you will monitor throughout their treatment. This is called a vital sign sheet or an assessment sheet.
Collecting Data
The first step in any nursing process is to collect data about your patient. At a minimum, you’ll need their name, birth date, contact information, and health history. You may also want to note their chief complaint—the reason why they’re seeking care at that moment.
Types of Data
There are five types of data that nurses collect: subjective, objective, psychosocial, documentary, and physiological. While all are important and collected for different reasons in order to gain a complete picture of a patient’s health, there is some overlap among them.
Subjective data includes information obtained through interviews with patients (including children) and their families; family members may be able to provide valuable information if they can accurately recall what has been happening with their loved ones.
Objective Data or Signs
Since nursing is a scientific discipline, objective data or signs play an important role in developing a nursing diagnosis. Several sources of objective data or signs include vital signs and laboratory studies.
Physical examination, medical history, and assessment of other data help with establishing a nursing diagnosis. Observation of client behavior can reveal important information about such things as activities of daily living, effects of treatment, intake and output, psychosocial status, function before the onset of illness or injury, family situation and support systems as well as self-care behaviors.
Subjective Data or Symptoms
Patients describe their condition as subjective data or symptoms. For example, a patient may describe an open wound as painful, swollen, and warm. The nurse describes these subjective data in objective language by asking questions about the location, description, and intensity of symptoms or data. For example, Where is your pain located? Describe your wound. What do you mean by itchy?
Verbal Data
The first step in your nursing assessment is verbal data collection. It’s always a good idea to ask any questions you might have about their condition before you start physically assessing them.
You should try and cover everything with your patient that may affect how they will be treated throughout their stay at your facility. This includes asking if they have any specific needs or allergies.
Nonverbal Data
This type of data is obtained through observation, and it doesn’t involve words. For example, nonverbal data might consist of a person frowning, raising their eyebrows or fidgeting while they are talking. Understanding these nonverbal cues can help improve patient outcomes because it allows nurses to pay attention to more than just what a patient is saying and can help identify if something may be wrong.
Sources of Data
In order to develop an assessment, information must be gathered. This can include patient medical history, interviews with family members or other caregivers, and diagnostic testing. The nurse gathers clinical data from a variety of sources: vital signs; physical examination findings; laboratory studies; diagnostic imaging results; and assessments from other health care professionals such as physicians, nutritionists, physical therapists, and speech pathologists.
Methods of Data Collection
There are a variety of ways that data can be collected. Here is a list of some of those methods
Health Interview
Conducting a health interview with a client is an important first step in care. The goal of any health interview is to gather information from you and your client about his or her present state of health, identify potential risks, and assess needs for future care.
By taking a thorough history during each session, you can ensure that you have accurate information about your clients’ current situation as well as any past medical problems or surgeries they may have experienced. Here are some tools to help make sure your next health interview goes smoothly.
Physical Examination
This is an important part of any medical evaluation, and it can be done by a doctor. However, if you are concerned about a specific condition or have reason to believe you may have something serious going on, it’s probably best that you see a nurse for your physical exam.
Nurses are trained professionals who will be able to tell if there’s a problem and help ensure your health needs are met accordingly.
Observation
The first step in diagnosing a patient is assessing their symptoms and examining their health history. This means watching them closely, listening closely, and taking an extensive medical history.
If you want to determine what’s causing a patient’s symptoms, you must observe them closely (like Sherlock Holmes!) with each encounter. Find out everything you can about your patients before jumping to conclusions; it will save you time and money in both diagnosis and treatment down the road.
Validating Data
Making Sense of Your Research – It’s very easy in research, especially nursing research, to lose track of what you’re really looking for. This is why validating data is so important. Validation allows you to set criteria and figure out how your findings support or refute that criteria. Essentially, validation makes sure your hypothesis isn’t based on an off-handed remark from a patient or piece of information in an outdated study.
Documenting Data
Recording data accurately is one of your most important nursing responsibilities. It’s a responsibility that can have a lasting impact on your patients’ recovery and overall health, so it’s crucial that you document everything in an accurate, clear manner. The first step in any medical charting system is reviewing each patient’s chart and identifying all information pertinent to their care. Are they allergic to any medications? Are they taking any vitamins or herbal supplements?
Diagnosis: “What is the problem?”
To find an answer to a patient’s needs, nurses must perform a thorough evaluation that includes gathering information from different sources and using objective tests. Nurses diagnose a patient by identifying his or her ailments, health problems, and medical issues.
The nurse will then identify any risks and possible complications for each patient. Some of these diagnoses require immediate action in order to keep patients safe and help them heal quickly. To provide safe nursing care, nurses work collaboratively with other healthcare providers so that all aspects of the treatment are covered.
Planning: “How to manage the problem?”
The planning phase is all about identifying symptoms and possible causes, analyzing patient information, and forming a plan of action. When faced with a new problem, nurses first brainstorm possible courses of action.
Once they’ve narrowed it down to two or three possibilities, they move onto implementing their plan (the actual nursing process). Depending on how serious/complex a case is, however, patients may require care from more than one caregiver.
Types of Planning
Nursing, like other healthcare fields, is governed by national and state laws. Nurses are required to abide by these rules when caring for patients in a professional and legal manner.
and how they plan to treat the patient for thaire recovery its types of planing
- Initial Planning
- Ongoing Planning
- Discharge Planning
Developing a Nursing Care Plan
Every nurse needs a care plan! In most organizations, nurses are responsible for creating care plans for each of their patients. This can be an overwhelming task for new nurses, so it’s important to break down some of these processes. By learning about all aspects of nursing, you’ll be more prepared and ready to meet your patient’s needs.
Implementation
In order for a nursing intervention to have its intended outcome, it must be implemented properly. For example, if an occupational therapist was implementing interventions designed to help a patient learn how to feed him or herself again, he or she would want to make sure they included information on how much and what type of food a patient should eat.
The implementation stage is perhaps one of the most crucial parts of your nursing process.
Nursing Interventions Classification (NIC) System
The NIC system is designed to make it easier for nurses, medical practitioners, and other hospital staff members to identify care areas based on their severity. According to their website, the NIC is a standardized way of organizing nursing diagnoses into groups that are related to clinical outcomes (goal). The NIC has become an industry-standard in healthcare and each year hundreds of new diagnoses are added.
Behavioral Nursing Interventions
Nurses who work with patients on behavioral issues such as substance abuse, self-harm, and mental illness often develop a structured nursing process for these situations. Behavioral health patients require a different level of care than a typical hospital or clinic patients,
so a nursing process is necessary for nurses to provide timely, appropriate interventions. The behavioral health nursing process includes four steps: assessment, formulation, intervention development, and evaluation.
Community Nursing Interventions
The most common nursing interventions center around community-based care, with programs such as home health aides and day programs for those who have trouble leaving their homes.
Additionally, many nursing professionals work in schools to teach kids about healthy habits like eating well and exercising. Community-based nurses also develop exercise routines for hospital patients to reduce pain and help them heal more quickly.
Family Nursing Interventions
The nursing process is broken into three major stages: assessment, intervention, and evaluation. At each stage, there are specific interventions that nurses use depending on their findings during the assessment.
This includes when they find a patient in a family state of mind versus an individual state of mind. In addition, many times a nurse will encounter more than one problem during any given encounter with a patient and thus have to manage multiple problems at once.
Health System Nursing Interventions
The nursing process and health system interventions are crucial for proper patient care. Health system interventions guide healthcare providers in developing a care plan for patients, especially those who are recovering from injury or illness.
Through providing assessment, intervention, and evaluation, nurses help their patients safely recover from injury or illness. Assessment includes a medical history review and physical examination of the patient’s vital signs.
Physiological Nursing Interventions
Accurately assessing a patient’s physiological state is critical. By identifying abnormal function, interventions can be designed to correct or reverse symptoms and return a patient to homeostasis (more on interventions later).
A thorough examination of heart rate, respiratory rate, blood pressure, temperature, as well as other elements such as hydration status is all part of nursing assessments. Symptoms of distress such as nausea and pain should also be assessed during an assessment phase.
Safety Nursing Interventions
What Is Safety Nursing? How Can I Provide Safety and Prevention in Healthcare Settings? What Are Common Safety Nursing Interventions? How Do You Administer Safety Interventions and Protocols? What Are Common Teaching Methods for Teaching Patients, Families, Caregivers, and Other Health Professionals About a Specific Health Condition? How Do I Record My Patient’s Status After a Nursing Intervention or Assessment Is Performed in a Care Setting?
Skills Used in Implementing Nursing Care
There are many different nursing care concepts and processes that a nurse may encounter while in school, working in a hospital or clinic, or even trying to pick up new skills in self-study. Some of these skills include patient assessment, diagnosis and treatment planning, documentation, patient education, and follow-up activities. These are just some of the basic skills that should be considered when learning about nursing theory on an academic level.
Process of Implementing
The nursing process is typically used by professional nurses throughout their careers. It allows them to provide a patient with the care that is safe, efficient, and effective. To ensure a patient receives quality care, healthcare professionals must use proven medical practices as outlined in Evidence-Based Practice (EBP).
The nursing process also ensures RNs are accountable for ensuring every step of providing quality care, including monitoring patients’ progress and addressing any questions or concerns patients may have about their health or treatment plan.
Supervising the delegated care
Once a health professional has decided upon a treatment plan, they will make sure it is carried out properly by another healthcare worker. This is why it’s so important for health professionals to have good communication skills as well as leadership qualities; they need to communicate and delegate effectively if they are going to supervise someone else’s work without creating any potential complications.
Documenting nursing activities
Registered nurses, or RNs, have to document their activities, treatments and more throughout their shifts. Whether you’re an RN or student in a program that will lead you there, it’s important that you understand how and why these records are used. Nurses must keep track of everything they do while they’re on duty in case of legal complications.
Evaluation:
Since nursing is a profession centered on helping people, it’s also important that nurses understand their patients as well as possible. This is why evaluation is one of nursing’s main activities; nurses must evaluate their patients and then diagnose what ails them in order to treat them appropriately.
The different forms of evaluation range from basic screening tests, such as blood pressure checks and temperature measurements, to more intensive diagnostic procedures like CT scans or exploratory surgery.
Steps in Evaluation
Before you can begin evaluation of a patient, or decide whether a person is ready for discharge from your care, you must first assess their condition. To do so effectively and accurately, follow these steps
Collecting Data
Nurses use their training and their senses to gather relevant data from multiple sources. This can be everything from health history and medical records, to medications, vital signs, and daily changes in a patient’s condition.
It can also include information gathered through physical examination or clinical trials. The purpose of gathering data is twofold: First, it allows nurses to understand each patient’s unique needs; second, it helps them create treatment plans that are personalized for every individual.
Comparing Data with Desired Outcomes
The way a medical professional makes decisions on whether or not a patient is doing well and heading towards improvement, boils down to comparing their current data and metrics with their desired outcomes.
A professional will look at if they are within the target range of all relevant factors, including things like temperature, blood pressure, glucose levels, organ function, etc. This is an important step in determining how a patient is doing—to monitor them along the way and adjust medications as needed.
Analyzing Client’s Response Relating to Nursing Activities
The best way to assess a client’s response is through talking and observing their actions. These actions will allow you to figure out if they are comprehending and/or complying with your orders. When conducting an assessment, begin by getting your client’s name and understanding what happened during his or her encounter with healthcare staff.
It’s important that clients understand that it is ok for them not to remember every detail surrounding their visit, so don’t be discouraged if they can’t recall everything.
Identifying Factors Contributing to Success or Failure
Once you’ve gathered some preliminary data and observed your patient, it’s time to identify what factors may be contributing to his or her illness or response. Ask yourself: Is your patient a smoker? Did he recently undergo surgery? Has he been diagnosed with a chronic condition like hypertension or diabetes? Is he depressed? What about his diet? Maybe he just started a new job that’s incredibly stressful.
Continuing, Modifying, or Terminating the Nursing Care Plan
The nursing care plan is an outline of your goals for patient care. When you’re done with an initial assessment, it’s time to decide if you need to continue or modify your plan or end it completely. Be aware that continuing a nursing care plan will help keep you organized and focused.
Plus, once a plan is in place, it can provide patients with a sense of continuity and predictability when dealing with various health conditions.
Discharge Planning
Nurses have a responsibility not only to provide for their patients’ immediate needs but also for their discharge needs. The more you can take care of in advances, such as prescriptions and follow-up appointments, will help ensure that your patient is fully prepared for discharge.
Coordinate with other caregivers—such as physical therapists and speech therapists—to make sure everyone is on board with your plan of care. Your goal should be to get your patient home or into an alternative care setting as quickly and safely as possible.
Why is There a Need for Standardized Procedure?
The standardized procedure is important because it provides a set of guidelines to follow that can ensure accuracy, consistency, and quality of care.
It also provides consistency from one nurse to another so that all patients are given proper care.
When there is standardization in both process and practice, there will be an increase in patient satisfaction as well as improved long-term outcomes. This increases overall value for patients while reducing unnecessary costs incurred by hospitals and insurance companies.
Factors that Influence Implementation and Application of the Nursing Process
The nursing process is not an in-and-out type of job. Instead, it is a continuous function that begins with data collection and ends with documentation.
However, there are factors that affect how each individual nurse applies his or her skills and knowledge in a clinical setting.
Being aware of these factors helps nurses manage their patients better as well as improve their own practice.