The Nursing Process-easy as 1, 2, 3
Many nursing students struggle with organizing patient care. Management of patient care makes up 17- 23% of the current NCLEX-RN exam. For a nurse to achieve mastery in management of nursing care, it is essential for nurses to possess skills in developing nursing care plans for patients.
Similar to the steps of a science experiment, the nursing profession uses the steps of the nursing process to build a care plan. The nursing process is a systematic problem solving method of delivering individualized care These steps will be discussed below:
Assessment (DATA COLLECTION)
This is the step of nursing process where we collect information about our clients and a comprehensive database regarding the client is established.
The data collected may be objective or subjective data. Objective data is said to be the data that the nurse observes or measures and may be described as signs or symptoms. Assessment data may be considered the factual data that supports the nursing diagnosis. Components of the assessment data may include the patient’s medications, and lab reports etc. The data collected in assessment is clustered, and validated.
DIAGNOSIS (Statement describing client’s need or problem identified from analysis of assessment)
The second step of the nursing process is the step of diagnosis. The nursing diagnosis is different from the medical diagnosis because the nursing diagnosis is a summary of the patients need or a statement describing the patient's problem/response to a disease process. When client problems are identified from the assessment data, the nurse labels the current problems or potential problems with applicable nursing diagnostic labels from NANDA listings. Nursing diagnoses have three components and must be supported by the information collected in assessment.
NANDA label that describes problem
Etiology or related to factor associated with problem or identified client needs.
Evidence of the client problem/identified need that is supported by assessment and may be retrieved directly from assessment info. This third component of the nursing diagnostic statement is usually described “as manifested by” or “as evidenced by”
To complete this step, the nurse should consider what are the patient’s needs/problems?
PLANNING
This is the step of the nursing process where the nurse identifies the client’s needs and develops criteria for expected client outcomes. This step of the process facilitates prioritization of life threatening concerns. The nurse develops strategies to correct, reduce or prevent a client problem. This step involves the plan for achievement of client outcomes, and the nurse actually records a plan of care. The nurse develops interventions, creates the care plan and develops goals to identify and communicate the nursing actions to be done. Goals for clients should be specific, measurable, attainable, relevant/realistic and have a time component for expected evaluation for the goal. They must all be client centred and singular.
IMPLEMENTATION
This is the step of the nursing process that encompasses client advocacy including client teaching, delegating, supervising and evaluating the work of others. The step of implementation includes initiation and completion of interventions, collaboration/delegation and the documentation of the plan of care. Prior to completion of nursing actions the nurse should utilize good judgment, decision making and re-assessment. During this step the nurse completes the nursing actions identified in the planning phase of the process.
EVALUATION
Evaluation is usually continuous throughout the nursing process. During this step, the nurse decides if the nursing interventions were effective or helpful in meeting the desired client outcomes. Evaluation of client goals is done to determine if goals were achieved. A decision is made to discontinue, continue or revise the current plan. The nurse uses the step of evaluation to make clinical decisions or to redirect client care.
You may purchase NCLEX textbooks for more information on the nursing process.