THE NURSING PROCESS

Definition and Purpose

The nursing process is defined as a scientific process that nurses use to ensure patient care quality.    The nursing process has dramatically evolved with time and is now used throughout the world in healthcare systems as an organizing framework for individualized personal care.    This process is cyclical and on-going, generally used together with various theoretical nursing philosophies or models. It is the essential core of practice for registered nurses to deliver holistic, patient-focused care and the common thread that unites the different types of nurses working in varied areas.

The five steps of the Nursing Process

Step 1: Assessment

The first phase and is concerned with data gathering. During this phase, a nurse gathers the patient’s information regarding his/her physiological, psychological, sociological, spiritual status, economic, and lifestyle factors. This data can be collected in various ways, either subjective (described by the patient) or objective (observed by the nurse). Methods:

             Client/patient interview

             Physical examination

             Family report/history

             Obtaining a health history (including dietary data)

Step 2: Diagnosis

The second phase is concerned with identifying the client’s health needs.  The nurse has to make a clinical judgment on the actual or potential health problems. The main activities in this phase are to interpret and analyze data:

             Compare data against standards

             Cluster or group data

             Identify gaps and inconsistencies

Step 3: Planning

Based on assessment and diagnosis, the nurse sets achievable and measurable short- and long-range goals for the patient. The aim here is to address each of the specific problems identified in the diagnosis phase.  Other activities include; communicating care plans to relevant health care providers, writing nursing care orders and nursing care plans.

 

Step 4: Implementation

The fourth phase, also known as the action phase. Here the nurse carries out or delegates actions previously planned.  The purpose here is to help the patient meet desired outcomes/goals, restore health, promote wellness and disease, and cope with altered functions.

Step 5: Evaluation

The final phase where the nurse judges whether actions implemented have successfully prevented or treated the client’s health problems/ progress toward the goals. If progress toward the goal/outcome is slow or regression has occurred, the nurse must change the care plan accordingly. Contrarily, if the goal/outcome has been achieved, then the care can stop.

All nurses must have a clear understanding of the steps of the nursing process. Nursing students must therefore also be familiar with the process.