The Nursing Process
Over time, the nursing process expanded to five steps and has gained widespread acceptance as the basis for providing effective nursing care. Nursing process is now included in the conceptual framework of all nursing curricula, is accepted in the legal definition of nursing in the Nurse Practice Acts of most states, and is included in the ANA Standards of Clinical Nursing Practice.
The five steps of the nursing process consist of the following:
The five steps of the nursing process consist of the following:
- Assessment is an organized dynamic process involving three basic activities: a) systematically gathering data, b) sorting and organizing the collected data, and c) documenting the data in a retrievable fashion. Subjective and objective data are collected from various sources, such as the client interview and physical assessment. Subjective data are what the client or significant others report, believe, or feel, andobjective data are what can be observed or obtained fromother sources, such as laboratory and diagnostic studies,old medical records, or other healthcare providers. Usinga number of techniques, the nurse focuses on eliciting aprofile of the client that supplies a sense of the client’s overall health status, providing a picture of the client’s physical,psychological, sociocultural, spiritual, cognitive, and developmental levels; economic status; functional abilities; and lifestyle. The profile is known as the client database.
- Diagnosis/need identification involves the analysis of collected data to identify the client’s needs or problems, also known as the nursing diagnosis. The purpose of this step is to draw conclusions regarding the client’s specific needs or human responses of concern so that effective care can be planned and delivered. This process of data analysis uses diagnostic reasoning (a form of clinical judgment) in which conclusions are reached about the meaning of the collected data to determine whether or not nursing intervention is indicated. The end product is the client diagnostic statement that combines the specific client need with the related factors or risk factors (etiology), and defining charac-
teristics (or cues) as appropriate. The status of the client’s needs are categorized as actual or currently existing diagnoses and potential or risk diagnoses that could develop due to specific vulnerabilities of the client. Ongoing changes in healthcare delivery and computerization of the client record require a commonality of communication to ensure continuity of care for the client moving from one setting/level of healthcare to another. The use of standardized terminology or NANDA International nursing diagnosis labels provides nurses with a common language for identifying client needs. Furthermore, the use of standardized nursing diagnosis labels also promotes identification of appropriate goals, provides acuity information, is useful in creating standards for nursing practice, provides a base for quality improvement, and facilitates research supporting evidence-based nursing practices. - Planning includes setting priorities, establishing goals, identifying desired client outcomes, and determining specific nursing interventions. These actions are documented as the plan of care. This process requires input from the client/ significant others to reach agreement regarding the plan to facilitate the client taking responsibility for his or her own care and the achievement of the desired outcomes and goals. Setting priorities for client care is a complex and dynamic challenge that helps ensure that the nurse’s attention and subsequent actions are properly focused. What is perceived today to be the number one client care need or appropriate nursing intervention could change tomorrow, or, for that matter, within minutes, based on changes in the client’s condition or situation. Once client needs are prioritized, goals for treatment and discharge are established that indicate the general direction in which the client is expected to progress in response to treatment. The goals may be shortterm—those that usually must be met before the client is discharged or moved to a lesser level of care—and/or long-
term, which may continue even after discharge. From these goals, desired outcomes are determined to measure the client’s progress toward achieving the goals of treatment or the discharge criteria. To be more specific, outcomes are client responses that are achievable and desired by the client that can be attained within a defined period, given the situation and resources. Next, nursing interventions are chosen that are based on the client’s nursing diagnosis, the established goals and desired outcomes, the ability of the nurse to successfully implement the intervention, and the ability and the willingness of the client to undergo or participate in the intervention, and they reflect the client’s age/situation and individual strengths, when possible. Nursing interventions are direct-care activities or prescriptions for behaviors, treatments, activities, or actions that assist the client in achieving the measurable outcomes. Nursing interventions, like nursing diagnoses, are key elements of the knowledge of nursing and continue to grow as research supports the connection between actions and outcomes (McCloskey & Bulechek, 2000). Recording the planning step in a written or computerized plan of care provides for continuity of care, enhances communication, assists with determining agency or unit staffing needs, documents the nursing process, serves as a teaching tool, and coordinates provision of care among disciplines. A valid plan of care demonstrates individualized client care by reflecting the concerns of the client and significant others, as well as the client’s physical, psychosocial, and cultural needs and capabilities. - Implementation occurs when the plan of care is put into action, and the nurse performs the planned interventions. Regardless of how well a plan of care has been constructed, it cannot predict everything that will occur with a particular client on a daily basis. Individual knowledge and expertise and agency routines allow the flexibility that is necessary to adapt to the changing needs of the client. Legal and ethical concerns related to interventions also must be considered. For example, the wishes of the client and family/significant others regarding interventions and treatments must be discussed and respected. Before implementing the interventions in the plan of care, the nurse needs to understand the reason for doing each intervention, its expected effect, and any potential hazards that can occur. The nurse must also be sure that the interventions are a) consistent with the established plan of care, b) implemented in a safe and appropriate manner, c) evaluated for effectiveness, and d) documented in a timely manner.
- Evaluation is accomplished by determining the client’s progress toward attaining the identified outcomes and by monitoring the client’s response to/effectiveness of the selected nursing interventions for the purpose of altering the plan as indicated. This is done by direct observation of the client, interviewing the client/significant other, and/or reviewing the client’s healthcare record. Although the process of evaluation seems similar to the activity of assessment, there are important differences. Evaluation is an ongoing process, a constant measuring and monitoring of the client status to determine: a) appropriateness of nursing actions, b) the need to revise interventions, c) development of new client needs, d) the need for referral to other resources, and e) the need to rearrange priorities to meet changing demands of care. Comparing overall outcomes and noting the effectiveness of specific interventions are the clinical components of evaluation that can become the basis for research for validating the nursing process and supporting evidenced-based practice. The external evaluation process is the key for refining standards of care and determining the protocols, policies, and procedures necessary for the provision of quality nursing care for a specific situation or setting.
Read More
Add your Comment
0
comments
Application of the Nursing Process
The scientific method of problem-solving introduced in the previous section is used almost instinctively by most people, without conscious awareness.
FOR EXAMPLE While studying for your semester finals, you snack on pepperoni pizza. After going to bed, you are awakened by a burning sensation in the center of your chest.You are young and in good health and note no other symptoms (assessment).You decide that your pain is the result of the spicy food you have eaten (diagnosis).You then determine that before you can return to sleep, you first need to relieve the discomfort with an over-the-counter preparation (planning).You take a liquid antacid for your discomfort(implementation).Within a few minutes, you note the burning sensation is relieved, and you return to bedwithout further concern (evaluation).
As you see, this is a process you routinely use to solve problems in your life that can be readily applied to client-care situations. You need only to learn the new terms describing the nursing process, rather than having to think about each step (assessment, diagnosis/need identification, planning, implementation, and evaluation) in an entirely new way.
To effectively use the nursing process, the nurse needs to possess and apply some basic abilities. Particularly important is a thorough knowledge of science and theory, not only as applied in nursing but also in other related disciplines such as medicine and psychology. Creativity is needed in the application of nursing knowledge as well as adaptability in handling change and the many unexpected happenings that occur. As a nurse, you must make a commitment to practice your profession in the best possible way, trusting in yourself and your ability to do your job well and displaying the necessary leadership to organize and supervise as your
position requires. In addition, intelligence, well-developed interpersonal skills, and competent technical skills are essential.
position requires. In addition, intelligence, well-developed interpersonal skills, and competent technical skills are essential.
FOR EXAMPLE A diabetic client’s irritable behavior could be the result of low serum glucose or the effects of excessive caffeine intake. However, it could also arise from a sense of helplessness regarding life events. A single behavior may have varied causes. It is important that your nursing assessment skills identify the underlying etiology to provide appropriate care.
The practice responsibilities presented in the definitions of nursing and the nursing process are explained in detail in the publication Nursing: Scope & Standards of Practice. The standards provide workable guidelines to ensure that the practice of nursing can be carried out by each nurse. Table 1–1 presents an abbreviated description of the standards of clinical practice. With the ultimate goal of quality healthcare, the effective use of the nursing process will result in a viable nursing-care system that is recognized and accepted as nursing’s body of knowledge and that can be shared with other healthcare professionals.
TABLE 1–1
ANA STANDARDS OF NURSING PRACTICE
Standards of Practice
Describes a competent level of nursing care as demonstrated by the nursing process that encompasses all significant actions taken by the nurse in providing care and forms the foundation of clinical decision making.
1. Assessment:The registered nurse collects comprehensive data pertinent to the patient’s health or situation.
2. Diagnosis:The registered nurse analyzes the assessment data to determine the diagnoses or issues.
3. Outcome Identification:The registered nurse identifies expected outcomes for a plan individualized to the patient or the situation.
4. Planning:The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.
5. Implementation:The registered nurse implements the identified plan.
a. Coordination of Care:The registered nurse coordinates care delivery.
b. Health Teaching and Health Promotion:The registered nurse employs strategies to promote health and a safe environment.
c. Consultation:The advanced practice registered nurse and the nursing role specialist provide consultation to influence the identified plan, enhance the abilities of others, and effect change.
d. Prescriptive Authority and Treatment:The advanced practice registered nurse uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations.
6. Evaluation:The registered nurse evaluates progress toward attainment of outcomes.
Standards of Practice
Describes a competent level of nursing care as demonstrated by the nursing process that encompasses all significant actions taken by the nurse in providing care and forms the foundation of clinical decision making.
1. Assessment:The registered nurse collects comprehensive data pertinent to the patient’s health or situation.
2. Diagnosis:The registered nurse analyzes the assessment data to determine the diagnoses or issues.
3. Outcome Identification:The registered nurse identifies expected outcomes for a plan individualized to the patient or the situation.
4. Planning:The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.
5. Implementation:The registered nurse implements the identified plan.
a. Coordination of Care:The registered nurse coordinates care delivery.
b. Health Teaching and Health Promotion:The registered nurse employs strategies to promote health and a safe environment.
c. Consultation:The advanced practice registered nurse and the nursing role specialist provide consultation to influence the identified plan, enhance the abilities of others, and effect change.
d. Prescriptive Authority and Treatment:The advanced practice registered nurse uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations.
6. Evaluation:The registered nurse evaluates progress toward attainment of outcomes.
Standards of Professional Performance
Describes roles expected of all professional nurses appropriate to their education, position, and practice setting.
7. Quality of Practice:The registered nurse systematically enhances the quality and effectiveness of nursing practice.
8. Education:The registered nurse attains knowledge and competency that reflects current nursing practice.
9. Professional Practice Evaluation:The registered nurse evaluates one’s own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations.
10. Collegiality:The registered nurse interacts with and contributes to the professional development of peers and colleagues.
11. Collaboration:The registered nurse collaborates with patient, family, and others in the conduct of nursing practice.
12. Ethics:The registered nurse integrates ethical provisions in all areas of practice.
13. Research:The registered nurse integrates research findings into practice.
14. Resource Utilization:The registered nurse considers factors related to safety, effectiveness, cost, and impact on practice in the planning and delivery of nursing services.
15. Leadership:The registered nurse provides leadership in the professional practice setting and the profession.
Source: American Nurses Association. (2004). Nursing: Scope & Standards of Practice. Silver Spring, MD: Nursesbooks.org.
7. Quality of Practice:The registered nurse systematically enhances the quality and effectiveness of nursing practice.
8. Education:The registered nurse attains knowledge and competency that reflects current nursing practice.
9. Professional Practice Evaluation:The registered nurse evaluates one’s own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations.
10. Collegiality:The registered nurse interacts with and contributes to the professional development of peers and colleagues.
11. Collaboration:The registered nurse collaborates with patient, family, and others in the conduct of nursing practice.
12. Ethics:The registered nurse integrates ethical provisions in all areas of practice.
13. Research:The registered nurse integrates research findings into practice.
14. Resource Utilization:The registered nurse considers factors related to safety, effectiveness, cost, and impact on practice in the planning and delivery of nursing services.
15. Leadership:The registered nurse provides leadership in the professional practice setting and the profession.
Source: American Nurses Association. (2004). Nursing: Scope & Standards of Practice. Silver Spring, MD: Nursesbooks.org.
Read More
Add your Comment
0
comments
Advantages of Using the Nursing Process
There are many advantages to the use of the nursing process:
• The nursing process provides an organizing framework for meeting the individual needs of the client, the client’s family/significant other(s), and the community.
• The steps of the nursing process focus the nurse’s attention on the “individual” human responses of a client/group to a given health situation, resulting in a holistic plan of care addressing the specific needs of the client/group.
• The nursing process provides an organized, systematic method of problem-solving (while still allowing for creative solutions) that may minimize dangerous errors or omissions in caregiving and avoid time-consuming repetition in care and documentation.
• The use of the nursing process promotes the active involvement of clients in their healthcare, enhancing consumer satisfaction. Such participation increases clients’ sense of control over what is happening to them, stimulates problem-solving, and promotes personal responsibility, all of which strengthen the client’s commitment to achieving the identified goals.
• The use of the nursing process enables you as a nurse to have more control over your practice. This enhances the opportunity for you to use your knowledge, expertise, and intuition constructively and dynamically to increase the likelihood of a successful client outcome. This, in turn, promotes greater job satisfaction and your professional growth.
• The use of the nursing process provides a common language (nursing diagnosis) for practice, unifying the nursing profession. Using a system that clearly communicates the plan of care to coworkers and clients enhances continuity of care, promotes achievement of client goals, provides a vehicle for evaluation, and aids in the development of nursing standards. In addition, the structure of the process provides a format for documenting the client’s response to all aspects of the planned care.
• The use of the nursing process provides a means of assessing nursing’s economic contribution to client care. The nursing process supplies a vehicle for the quantitative and qualitative measurement of nursing care that meets the goal of cost-effectiveness and still promotes holistic care.
• The nursing process provides an organizing framework for meeting the individual needs of the client, the client’s family/significant other(s), and the community.
• The steps of the nursing process focus the nurse’s attention on the “individual” human responses of a client/group to a given health situation, resulting in a holistic plan of care addressing the specific needs of the client/group.
• The nursing process provides an organized, systematic method of problem-solving (while still allowing for creative solutions) that may minimize dangerous errors or omissions in caregiving and avoid time-consuming repetition in care and documentation.
• The use of the nursing process promotes the active involvement of clients in their healthcare, enhancing consumer satisfaction. Such participation increases clients’ sense of control over what is happening to them, stimulates problem-solving, and promotes personal responsibility, all of which strengthen the client’s commitment to achieving the identified goals.
• The use of the nursing process enables you as a nurse to have more control over your practice. This enhances the opportunity for you to use your knowledge, expertise, and intuition constructively and dynamically to increase the likelihood of a successful client outcome. This, in turn, promotes greater job satisfaction and your professional growth.
• The use of the nursing process provides a common language (nursing diagnosis) for practice, unifying the nursing profession. Using a system that clearly communicates the plan of care to coworkers and clients enhances continuity of care, promotes achievement of client goals, provides a vehicle for evaluation, and aids in the development of nursing standards. In addition, the structure of the process provides a format for documenting the client’s response to all aspects of the planned care.
• The use of the nursing process provides a means of assessing nursing’s economic contribution to client care. The nursing process supplies a vehicle for the quantitative and qualitative measurement of nursing care that meets the goal of cost-effectiveness and still promotes holistic care.
Read More
Add your Comment
36
comments
