A Quick Look at the Nursing Process

The nursing process is the way how nurses think and act in rendering care to patients. It can be considered as the foundation of nursing practice.

All nurses are trained to think in this framework which parallels the process of problem-solving and the scientific method. It consists of a series of steps or stages: assessment, diagnosis, planning, implementation, delegation. To be effective, nurses should know these steps by heart.

Assessment is the initial step in the nursing process. It is done prior to nursing diagnosis but is part of every other step in the process. During assessment, nurses collect data through observation, interview and examination. They then organize, validate and record the information to form a baseline for subsequent steps. No conclusions or judgements are made during assessment.

Diagnosis in the nursing process is different from medical diagnosis. Physicians diagnose the disease and nurses diagnose how patients response to the treatment for the disease. In this step, nurses analyze the data collected during assessment. Potential problem areas are identified and one or several nursing diagnoses are created. The North American Nursing Diagnosis Association has outlined specific statements to be used for nursing diagnosis.

Planning involves the joint effort between nurses and patients to look for solutions to the health problems of the patient. These solutions, called nursing interventions, are designed to meet care goals. During this step, health outcomes are identified and prioritized. The result of this collaboration is the nursing care plan which will be carried out in the implementation phase.

Implementation is when the nursing care plan is carried out. The nursing interventions identified during the planning stage are performed or delegated by the nurse. Care plans are to be validated among nurses and other members of the health care team for safety, effectiveness, appropriateness and for being individualized. The implementation stage ends when nurses document the care given and the patients’ responses to care.

Evaluation means noting how patients respond to nursing interventions and comparing this to the health outcomes identified earlier. Nurses determine how goals have been met and how to change them if necessary. During evaluation, the nursing care plan is reassessed and revised to better meet the needs of patients.

The nursing process consists of a series of steps that are integrated and overlapping. In nursing practice, it is dynamic and occurs in a never-ending loop. At any interaction between the nurse and the patient, the nursing process is always used. Nursing students and new nurses often struggle with the process because they see it as rigid and cumbersome. The ideal thing is to have the process ingrained in every nurse’s way of thinking that it becomes automatic and geared towards a holistic view of the patient. The quality of care given to patients will be improved if nurses follow the nursing process.

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