The nursing process is one of the essential tools a nurse can use in practice. Although nursing schools educate first-year students on the nursing process, some nurses are unaware of the impact proper use can have on patient care. In this article, we have discussed the nursing process, its history, purpose, key characteristics, and the five steps of a nursing process.
Furthermore, after discussing a nursing process step, we will provide an example of how the nurse would proceed with that step throughout this article. We will use the following patient’s information for the purposes of this article: Mr. Collie, a 54-year-old white male, was admitted to the Medical-Surgical floor with acute congestive heart failure.
What is Nursing Process?
The nursing process is a series of steps that nurses take to assess patients, plan and deliver patient care, and assess the patient’s response to care. It is regarded as the foundation upon which all nursing care is based.
The emergence of the Nursing Process
Lydia Hall introduced the first version of the nursing process in 1955. Ms. Hall identified three nursing process steps: observation, care administration, and validation. Throughout the next decade, different versions of the nursing process emerged. Dorothy Johnson defined nursing in 1959 as “promoting the client’s behavioral functioning.” Ms. Johnson’s nursing process consisted of three steps: assessment, decision, and nursing action. Finally, Ida Jean Orlando-Pelletier introduced the version of the nursing process that nurses are familiar with today in 1961.
Creator of Nursing Procedure
The nursing process as we know it today is based on Ida Jean Orlando-“Deliberative Pelletier’s Nursing Process Theory.” According to Ms. Orlando-Pelletier, the nursing process consists of five steps: assessment, diagnosis, planning, implementation, and evaluation.
What Is the Nursing Process All About?
The nursing process’s goal is to establish a standard of care in which nurses assess patients and develop plans of action to address individualized patient needs. Other purposes of the nursing process include, but are not limited to, the following:
- Develops plans to meet the needs of patients
- Assists nurses in providing high-quality, evidence-based care.
- Protects nurses from potential legal issues
- Encourages all nursing team members to use a systematic approach to patient care.
Critical Elements of the Nursing Process
Several characteristics are associated with nursing care. The seven attributes of the nursing process are listed below, along with an explanation for each.
1. Within the bounds of the legal scope of practice
Perhaps the most critical aspect of the nursing process is that it be used within the size of the nurse’s legal training.
2. Founded on solid knowledge
To use the nursing process effectively, the nurse must use nursing knowledge and skills to identify and resolve problems. Nurses should develop and maintain critical thinking skills as well as the use of evidence-based nursing interventions.
3. Prepared
A well-planned approach to patient care results in organized, systemic patient care that is efficient and orderly.
4. Customer-centered
Nurses must understand the significance of client-centered nursing care. The client-centered care nursing process assists nurses in planning care that is tailored to the patient. It also promotes patient autonomy, which is a fundamental right for all patients.
5. Goal-oriented
As the name implies, goal-directed care is a type of nursing care delivery based on achieving individualized goals to achieve desired patient outcomes. Plans are developed collaboratively by nurses, other members of the healthcare team, and patients.
When planning patient care, it is critical to identify all health issues and risk factors and prioritize patient care, beginning with the most severe issues. As you read further in this article about the nursing process steps, you will notice that the process is continuous and that nurses must repeat steps. The priorities in the care plan may change as assessments and evaluations continue, depending on the patient’s response to care.
6. Cyclical and dynamic
The nursing process is dynamic because the patient’s needs constantly influence it, circumstances impacting their needs, and the environment in which care is provided. It includes emotional, physical, social, and medical components. In a cycle of activity, other phases of the nursing process interact with and are influenced by different stages. The dynamics of the nursing care cycle continue from the time of admission until the patient is discharged.
Significance of a Nursing Plan
A nursing process is an excellent tool for assisting nurses in navigating the complexities of the healthcare system and providing optimal patient care in the intricate and dynamic world of nursing.
The nursing process implies that patient-centered care is delivered following a plan. It’s a good way for nurses to make better use of their time. It also encourages better communication among members of the healthcare team. Nursing process-generated written resources improve care quality and provide evidence for nursing education and research.
Furthermore, using the nursing process encourages nurses to practice critical thinking, creativity, and problem-solving and sharpen their clinical decision-making abilities. As a result, the quality of nursing care improves, as does patient satisfaction.
Steps in the Nursing Process
The nursing process consists of five steps that cover the care given. The five nursing process steps are as follows:
- Evaluation
- Prognosis
- Organization
- Application
- Assessment
The nursing process is one of the essential tools a nurse can use in practice. Although nursing schools educate first-year students on the nursing process, some nurses are unaware of the impact proper use can have on patient care. In this article, I will discuss the nursing process, its history, purpose, key characteristics, and the five steps involved in carrying out the nursing process.
Furthermore, after discussing a nursing process step, I will provide an example of how the nurse would proceed with that step throughout this article. We will use the following patient’s information for the purposes of this article: Mr. Collie, a 54-year-old white male, was admitted to the Medical-Surgical floor with acute congestive heart failure.
1. Phase of evaluation
During the assessment phase, the nurse will look at any subjective and objective data collected in the patient’s history. Accurate data could include charted oxygen saturation trends or documentation demonstrating that the patient’s oxygen liter flow was increased several times overnight. Subjective data could be information obtained during nursing handoff—for example, the overnight nurse may have mentioned that the patient appeared “air-hungry” and was using accessory muscles to breathe.
During the assessment phase, you will want to gather all of this information and assess what is going on. Your nursing evaluation begins before meeting the patient and continues throughout the shift. If the doctor asks if the patient looks worse than before, you can provide the information gathered during your nursing assessment.
2. Phase of Diagnosis
During the diagnosis phase, you will use your assessment findings to develop a few nursing diagnoses that will guide your care for the shift. A nursing diagnosis is distinct from a medical diagnosis and is based on your nursing judgment. The physician must make a medical diagnosis, such as “acute respiratory failure.”
A nursing diagnosis should be more focused on the issues your patient will face during your shift, such as “impaired gas exchange” or “risk of impaired mobility.” You’re already prioritizing the patient’s needs by creating a nursing diagnosis.
Because patients frequently have multiple issues, you should use Maslow’s hierarchy of needs to prioritize these issues. Addressing the patient’s oxygen needs, for example, is more important than their ability to go for a walk. Developing nursing diagnoses based on your information about this patient will help you anticipate any issues that may arise during your shift.
3. The planning stage
The planning phase, also known as the outcomes phase, is the stage in which the nurse begins formulating a plan of action. The nurse will set some goals for the shift during this phase. What do you want to happen during your transition? Again, safety is the number one priority, so set goals that prioritize airway, breathing, and circulation first.
Your first objective could be, “The patient will maintain an oxygen saturation of at least 92 percent this shift.” The nurse must assign a simple, achievable, and measurable goal for a positive outcome for each medical issue. These are typically short-term objectives that are assessed on a shift-by-shift basis.
4. Phase of Implementation
What steps will you take as a nurse to ensure that these objectives are met? During the implementation phase, you will develop a few nursing interventions to assist the patient in reaching their goals. “Will titrate oxygen liter flow to maintain saturations above 92 percent this shift,” for example.
After you’ve addressed airway and breathing issues, you can develop additional action items to help you meet the planning phase’s goals. What will ensure that your patient’s oxygen levels remain stable? The following objectives could be, “Will encourage the patient to use incentive spirometry ten times per hour,” or “Will ambulate the patient three times per shift and encourage cough and deep breathing.”
5. Phase Evaluation
The evaluation phase is the final stage of the nursing process. It occurs after the interventions to determine whether the objectives have been met. The nurse will decide how to measure the success of the goals and interventions during the evaluation phase.
One evaluation tool for a patient with respiratory issues would be to track the patient’s oxygen saturation levels throughout the shift. “Were you able to wean off the oxygen, or did you have to increase the liter flow?”
The following are some possible outcomes that the nurse can use to categorize the intervention:
- The patient’s condition has improved: the patient maintained O2 saturations above 92 percent during this shift, there was no use of accessory muscles, and the patient is now off oxygen.
- The patient’s condition has stabilized: the nurse was able to wean the patient off oxygen this shift.
- The patient’s condition has worsened: the oxygen liter flow has been increased twice today; continue to monitor.
- Setting measurable goals allows you to tailor the patient’s treatment plan if the goals are not met.
Conclusion
The article has very crucial information on the steps of the nursing process. Your nursing education should prepare you to confidently apply the nursing process and all of its steps in your future career. Nightingale College’s nursing programs will ensure that you enter nursing practice prepared to provide the best patient care possible through the nursing process.
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