The nursing process is the framework for providing professional, quality nursing care. It directs nursing activities for health promotion, health protection, and disease prevention and is used by nurses in every practice setting and specialty.
Characteristics of Nursing Process
A process is a series of steps or acts that lead to accomplishing some goal or purpose. Processes have three characteristics: 1. Inherent purpose. 2. Internal organization. 3. Infinite creativity.
Components of Nursing Process
The nursing process is a systematic method for providing care to clients. The nursing process is dynamic and requires creativity in its application. The steps are the same for each client situation, but the correlation and results will be different. The nursing process is used with clients of all ages and in any care setting
The first step in the nursing process includes systematic collection, verification, organization, interpretation, and documentation of data. The completeness and correctness of this data relate directly to the accuracy of the steps that follow.
• Data collection from a variety of sources
• Data validation
• Data organization
• Data interpretation
• Data documentation
The second step in the nursing process involves further analysis (breaking down the whole into parts that can be examined) and synthesis (putting data together in a new way) of the collected data. A list of nursing diagnoses is the result of this process.According to NANDA-International, a nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. Clients have both medical and nursing diagnoses.
Analysis of the collected data leads the nurse to make a diagnosis in one of three categories:
• An actual nursing diagnosis: indicates that a problem exists; it is composed of the diagnostic label, related factors, and signs and symp toms.
• Arisk nursing diagnosis (potential problem): indicates that a problem does not yet exist but that specific risk factors are present. Risk for followed by the diagnostic label and a list of the risk factors.
• A wellness Nursing Diagnosis: denotes the client’s statement of a desire to attain a higher level of wellness in some area of function. It begins with the phrase Readiness for Enhanced followed by the diagnostic label
Nursing Planning and Outcome Identification
Planning and outcome identification are the third step of the nursing process and include both establishing guidelines for the proposed course of nursing action to resolve the nursing diagnoses and developing the client’s plan of care. The planning occurs in three phases: initial, ongoing, and discharge.
1. Initial planning: involves development of a preliminary plan of care by the nurse who performs the admission assessment and gathers the comprehensive admission assessment data. Progressively shorter stays in the hospital make initial planning very important to ensure resolution of the problems.
2. Ongoing planning: updates the client’s plan of care. New information about the client is collected and evaluated and revisions made to the plan of care.
3. Discharge planning: involves anticipation of and planning for the client’s needs after discharge.
The fourth step in the nursing process is implementation, the performance of the nursing interventions identified during the planning phase. It also involves the delegation (process of transferring a select nursing task to a licensed individual who is competent to perform that specific task) of some nursing interventions to staff members or assigning a specific nursing task to assistive (unlicensed) personnel capable of competently performing the task. The nurse is accountable for appropriate delegation and supervision of care provided by unlicensed personnel.
Evaluation, the fifth step in the nursing process, determines whether client goals have been met, partially met, or not met. When a goal is met, the nurse decides whether nursing interventions should stop or continue for the status to be maintained. When a goal is partially met or not met, the nurse reassesses the situation. The reasons the goal is not met and modifications to the plan of care are determined by more data collection. Reasons that goals are not met or are only partially met include:
• Initial assessment data were incomplete.
• Goals and expected outcomes were unrealistic.
• Time frame was not adequate.
• Nursing interventions were not appropriate for the client or situation. Evaluation is a fluid process that depends on all the other components of the nursing process