Nursing process

Nursing process is a systematic method used by nurses to plan and deliver the appropriate nursing care to patients. The process is goal-oriented and patient-centered, ensuring that each patient receives individualized care based on their unique needs and circumstances.

Overview

The nursing process is a critical thinking method used by nurses to help ensure that all patient care is well planned, relevant, and effective. It is a systematic, rational method of planning and providing individualized nursing care. The purpose of this process is to identify a patient's health care needs, establish goals to meet those needs, and implement nursing interventions to achieve the goals.

Steps of the Nursing Process

The nursing process consists of five steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation. Each step is dependent on the previous step to move forward with patient care.

Assessment

The first step in the nursing process is assessment. During this phase, the nurse gathers information about a patient's physiological, psychological, sociological, and spiritual status. This data can be collected through physical examinations, interviews, and reviewing the patient’s medical history.

Diagnosis

The second step is diagnosis. The nurse makes a nursing diagnosis by interpreting and analyzing the collected data. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient.

Planning

The third step is planning. In this phase, the nurse sets achievable and measurable goals for their patient. Each goal must be patient-centered and directly related to the nursing diagnosis.

Implementation

The fourth step is implementation. The nurse carries out the plan of care that was established in the previous step. This can involve administering medication, educating the patient about their condition, or referring the patient to a specialist.

Evaluation

The final step is evaluation. The nurse evaluates whether the patient’s goals have been achieved and whether the nursing interventions were successful. If the goals were not met, the nurse revises the plan of care.

Importance of the Nursing Process

The nursing process is important because it provides a framework for individualized care to the patient. It ensures that care is continuous and consistent from shift to shift and from one healthcare provider to another. It promotes efficient nursing care by requiring that nurses complete documentation at each phase of the process.

See Also

• Nursing theory
• Nursing assessment
• Nursing diagnosis
• Nursing care plan
• Nursing documentation

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  Nurse's Chatelaine

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  Nursing process (NANDA)