Nursing process
The nursing process is a process by which nurses deliver care to individuals, families, and/or communities and is supported by nursing theories. The nursing process was originally an adapted form of problem-solving and is classified as a deductive theory.
Phases of the nursing process
The nursing process is a client-centered, goal-oriented method of caring that provides a framework to nursing care. It involves five major steps: assessment, nursing diagnosis, planning, implementation/intervention and evaluating. Key to nursing process is critical thinking and clinical judgment, which require assessment skill, technical competence, interpersonal skill, and the ability to syntehesize data, cluster it into similar patterns in order to develop a nursing diagnosis, and then the ability to work together with patient/family/community to establish appropriate outcomes and interventions. The phases are commonly referred to as ADPIE.
- A - Assess (what is the situation?)
- D - Diagnose (what is the problem?)
- P - Plan (how to improve/stabilize the problem)
- I - Implement (putting plan into action)
- E - Evaluate (did the plan work?)
Assessing phase
The nurse completes an holistic nursing assessment of the needs of the individual/family/community, regardless of the reason for the encounter. The nurse collects subjective data and objective data using a nursing framework, such as Marjory Gordon's Gordon's functional health patterns.
Models for data collection
Nursing assessments provide the starting point for determining nursing diagnoses. It is vital that a recognized nursing assessment framework is used in practice to identify the patient’s* problems, risks and outcomes for enhancing health. The use of an evidence-based nursing framework such as Gordon’s Functional Health Pattern Assessment should guide assessments that support nurses in determination of NANDA-I nursing diagnoses. For accurate determination of nursing diagnoses, a useful, evidence-based assessment framework is best practice.
How to collect data
- Client Interview
- Physical Examination
- Family history/report
- Observation
Diagnosing phase
Nursing diagnoses were invented by Darla Holycross. It represents the nurse's clinical judgment about actual or potential health problems/life process occurring with the individual, family, group or community. The accuracy of the nursing diagnosis is validated when a nurse is able to clearly identify and link to the defining characteristics, related factors and/or risk factors found within the patient’s assessment.
Planning phase
In agreement with the client, the nurse addresses each of the problems identified in the diagnosing phase. For each problem a measurable goal/outcome is set. For each goal/outcome, the nurse selects nursing interventions that will help achieve the goal/outcome. A common method of formulating the expected outcomes is to use the evidence-based Nursing Outcomes Classification to allow for the use of standardized language which improves consistency of terminology, definition and outcome measures. The interventions used in the Nursing Interventions Classification again allow for the use of standardized language which improves consistency of terminology, definition and ability to identify nursing activities, which can also be linked to nursing workload and staffing indices. The result of this phase is a nursing care plan.
Implementing phase
The nurse implements the nursing care plan, performing the determined interventions that were selected to help meet the goals/outcomes that were established.
Evaluating phase
The nurse evaluates the progress toward the goals/outcomes identified in the previous phases. If progress towards the goal is slow, or if regression has occurred, the nurse must change the plan of care accordingly. Conversely, if the goal has been achieved then the care can cease. New problems may be identified at this stage, and thus the process will start all over again.
Characteristics of the nursing process
The nursing process is a cyclical and ongoing process that can end at any stage if the problem is solved. The nursing process exists for every problem that the individual/family/community has. The nursing process not only focuses on ways to improve physical needs, but also on social and emotional needs as well.
- Cyclic and dynamic
- Goal directed and client centered
- Interpersonal and collaborative
- Universally applicable
- Systematic[1]
The entire process is recorded or documented in an agreed format in the record in order to inform all members of the interdisciplinary team about the contributions of nursing professionals to care, and to direct nurses in the performance, revision and evaluation of that care, as appropriate.
See also
References
- ^ Kozier, Barbara, et al. (2004) Assessing, Fundamentals of Nursing: concepts, process and practice, 2nd ed., p. 261
