You probably became über-familiar with the nursing process and care plansin nursing school. But what’s the nursing process definition? How do nurses follow these steps? Why are they so important?
In this article, we’ll answer those questions and more. You’ll learn about the five nursing process steps and explore examples of how they play out in real-word scenarios.
What Is the Nursing Process?
The nursing process is a uniform sequence of five steps nurses follow when assessing and caring for patients. It requires critical thinking, a patient-centered approach, knowledge of current evidence-based practices, and a nurse’s intuition. You’ll apply this process whether you’re working in onsite or remote nursing jobs.
What Are the Steps of the Nursing Process?
The nursing process steps are summarized in the acronym ADPIE. It stands for:
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
Let’s take a close look at how to complete the steps of the nursing process:
Step 1: Assessment
The nursing process steps begin with assessment. Before any clinical judgments or interventions are made, it’s crucial that an assessment is performed. This includes gathering objective and subjective data, past medical history, family history, and medication reconciliation.
Assessments also involve obtaining information about a patient’s physical, social, spiritual, mental, and emotional health. Nurses should also assess a patient’s lifestyle, economics, and cultural background.
Nurses follow systematic methods of performing assessments and collecting data on patients. For example, a physical assessment may be conducted via a head-to-toe assessment. There may also be focused assessments, where a nurse focuses on one specific problem or area of the patient’s life.
Example: A new patient is admitted to the unit. The nurse obtains the patient’s blood pressure, heart rate, respiration rate, temperature, and oxygen saturation. The nurse performs a head-to-toe assessment and gauges the patient’s pain level. The nurse documents this information.
Why Is Assessment Important?
Nursing care is not the time or place to be making assumptions. Assess, don’t guess! As a nurse, you are basing your entire care plan and interventions on your assessment. Without this step, the interventions may not be effective, as they may not be addressing the true problem.
A nursing process assessment is also essential for identifying major problems, prioritizing interventions, and considering expected outcomes. In fact, the initial assessment often identifies life-threatening conditions that need immediate interventions. As you can imagine, assessments can lead to better patient outcomes.
Step 2: Diagnosis
During the nursing process, the diagnosis step involves analyzing the information gathered from the assessment and drawing conclusions from it. But I thought nurses couldn’t diagnose? You are correct. Nurses cannot make medical diagnoses, but they can and do make nursing diagnoses.
A nursing diagnosis is essentially the nurse’s clinical judgment of a patient’s real or potential response to health issues or needs. Like medical diagnoses, they are regulated and follow a universal, standard framework. The North American Nursing Diagnosis Association (NANDA) develops nursing diagnosis definitions and terms, providing a uniform guide for all nurses to abide by when creating their nursing diagnosis for patients.
The nursing diagnosis framework follows a PES format: Problem + Etiology + Symptoms.
Example: After reviewing assessment information, the nurse determines an appropriate nursing diagnosis. The nurse’s diagnosis reads: Ineffective peripheral tissue perfusion related to decreased cardiac output as evidenced by pain in extremities, discoloration of skin, and lack of sensation in peripheral tissue.
Why Is Diagnosis Important?
The diagnosis determines the care plan and interventions to be implemented. Basically, the proper diagnosis corresponds with appropriate, specific interventions tailored to the exact problem the patient is experiencing. It also keeps the nurse’s focus on the patient as a whole, enabling the nurse to provide holistic, patient-centered care.
Step 3: Planning
The planning phase is where the nurse creates a care plan based on the assessment and nursing diagnosis. It involves selecting nursing interventions to implement, setting goals, and outlining implications and expected outcomes.
Example: After selecting a nursing diagnosis (ineffective peripheral tissue perfusion), the nurse creates a care plan.
Nursing interventions: monitor vital signs, assess for sudden changes, assess capillary refill, and monitor hemoglobin levels.
Expected outcomes: Patient will maintain adequate tissue perfusion as evidenced by strong pulses, warm skin to touch, normal skin coloration, and full sensation in extremities.
Why Is Planning Important?
Planning in the nursing process ensures that care and interventions are purposely selected and performed. It promotes intentionality, high-quality care, and continuity of care across providers.
Step 4: Implementation
In the nursing process steps, implementation is the actual, tangible practice of nursing care. The care plan guides the care provided, which allows several members of the healthcare team to participate in the implementation.
This step involves performing the planned nursing interventions, such as taking vital signs, monitoring lab values, providing wound care, raising the head of the bed, or palpating pulses.
Example: The nurse reviews the patient’s labs in the electronic medical record (EMR) and checks hemoglobin levels. The nurse also performs a focused assessment, checking capillary refill on the patient. This nurse is implementing the planned nursing interventions in their care plan.
Why Is Implementation Important?
You can make the best nursing care plan there is, but if you don’t act it out, it won’t benefit the patient. Implementation in the nursing process is the way to achieve goals and expected outcomes.
Step 5: Evaluation
The last of the nursing process steps is evaluation. The nurse must evaluate the effectiveness of the interventions, which requires assessment, monitoring, critical thinking, and revising the care plan when appropriate. You can use nursing outcomes classification to measure the patient’s response to your intervention.
Additional issues may arise or you may see that existing issues found upon initial assessment are now resolved. Although this is the last step, it is not the end of the process. Evaluation is an ongoing practice that follows each and every nursing intervention.
Example: The nurse obtains a patient’s blood pressure after administering an anti-hypertensive medication. The nurse evaluates the effectiveness of the medication. If the blood pressure remains elevated, the nurse knows another intervention is needed, such as calling the doctor or administering a PRN medication.
Why Is Evaluation Important?
Evaluation is how you know whether or not your intervention was effective. It alerts you if more or different interventions are needed. It also helps you assess your patient’s progress towards their goals and expected outcomes.
Nursing Process Steps In Order: Example
In general, the nursing process is carried out in order. This means that the nurse will first assess, then create a nursing diagnosis, and so on. However, some of these steps can occur at the same time.
Example: A nurse receives a new patient on the unit. Upon assessment, they find that the patient’s oxygen saturation is declining and they are using effort to breathe. The nurse thinks, “This patient has an ineffective breathing pattern related to COPD as evidenced by orthopnea, shortness of breath, and use of accessory muscles to breathe.”
They quickly think of a plan, which includes repositioning the patient, monitoring vital signs, and applying oxygen per orders. The nurse applies a continuous pulse oximeter to the patient’s finger, and initiates 2L of O2 via nasal cannula. In 15 minutes, the nurse evaluates the patient and obtains vital signs.
As you can see in the above nursing process examples, the process itself can be very dynamic when carried out. While nursing care plans can be written or created in the EMR, they also serve as an internal framework for the nurse throughout the shift as they care for patients.
Put the Nursing Process into Action
Now that you’ve learned (or reviewed) the nursing process steps, are you ready to implement them? Assess your current job and determine if it’s really serving you. Need help finding a better fit? IntelyCare can help you find the job that is the best match for you.
