Understanding the Nursing Process
A "process" is defined as a series of actions, changes, or functions bringing about a result, e.g. the process of digestion; the process of obtaining a college degree or a licensure. A process involves a series of operations performed in the making or treatment of a product, e.g., a manufacturing process like in fermentation in the wine making process.
The nursing process is a patient centered, goal driven cyclical process used by nurses as a problem-solving technique to provide optimal treatment to their patients. It is a systematic, dynamic, ongoing, interpersonal, and collaborative method that helps nurses in delivering a holistic care to the patients. The nursing process addresses every medical, psychological, and/ or social problem involved in patient care. It helps nurses in evaluating patient's health care needs during hospitalization. Implementation of the nursing care plan changes based on those needs on day to day basis.
Nursing care goal is focused on the holistic care of a person, and the nursing process is a means to reaching that goal and measure outcomes in a systematic manner. The nursing process involves five components or steps:1) Assessment2) Diagnosis3) Planning4) Implementation5) Evaluation (outcome based)
Assessment: Nursing assessment begins as soon as the nurse meets or sees the patient. A systematic data is collected to determine patients' health status and needs. The data is then documented as subjective and objective data. The subjective data is volunteered by the patient to the provider (pain, injury, health history), and objective data is based on observation (edema, skin discoloration, wounds) and measured data ( blood pressure, heart rate). The data collection is done by history taking and physical examination of the patient.
Diagnosis: Nursing diagnosis is different than the medical diagnosis. It is simple and to the point. A problem is identified and plan is established to solve the problem, and or prevent it from further complications. Its main purpose is to set a goal and take necessary action for treatment and prevention. For example, if a patient has skin breakdown. Then the diagnosis will be "alteration in skin integrity". There is a formal collection of nursing diagnosis approved by the North American Nursing Diagnosis Association (NANDA).
Planning: It is the next step after a problem is diagnosed. A plan of care is designed to treat the diagnosis. The treatment steps are listed in the care plan of the patient. The list of interventions listed in the care plan help to ensure that no needed steps are missed, even when nurses change between the various shifts.
Implementation: Taking the care to the patient- doing it. Carrying out the plan
Evaluation: Look at the outcome measures. Evaluate if the treatment plan was successful or not. If it was not successful then what else needs to be looked at. Change the plan accordingly. For example if the wound did not heal with the plan that had been devised, then evaluate the other reasons that could be contributing to the problem. Does patient need different nutrition, different bed, different dressing, and so on?
The evaluation process looks at outcomes. The nursing process is on a continuum, and the goal is to return the patient to their baseline or better health status.
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