Every shift for nurses is like a puzzle, multiple patients, multiple conditions, but even in chaos, nurses always know what each patient needs. Ever wondered how they do that? The secret behind safe, effective, and personalized patient care is the Nursing Process. Every nurse and travel nurse must master the nursing process to ensure every patient gets individualized attention and care. In this blog, we will discuss in detail the five steps of the nursing process, so let’s dive in!
Before we start, sign up now with SkillGigs so you can get access to high-paying travel nursing contracts. Explore top travel nurse assignments and get a $500 bonus once you sign your contract with us.
What is the Nursing Process?
The nursing process is a systematic, patient-centered care that nurses use to ensure high-quality and individualized care. It guides nurses to assess, diagnose, plan, implement, and evaluate patient care. The nursing process consists of five steps.
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
Five steps of the nursing process
Assessment
Assessment in the nursing process is the information that is collected from the patient to identify the patient’s physical, psychological, spiritual, and social health status. It consists of both subjective and objective data.
Subjective data: the information that is collected from the patient, what he tells and feels, and is not measurable. For example, nausea, pain, dizziness, etc.
Objective data: The information that is observed, tested, or measured by healthcare providers. For example, temperature (101°F), heart rate (99bpm), rash, swelling, etc.
What are the methods of assessment?
- Nurses use a systematic approach to make sure that nothing is missing
- Observing the patient, such as their appearance, movement, and behavior.
- Asking open-ended questions and collecting information about symptoms, medical history, and lifestyle.
- Physical examinations, like palpation, percussion, etc.
- Checking the lab results, such as tests, reports, and imaging results.
- Collecting information about health history, such as medications, allergies, family history, etc.
Tip: The Mnemonic for data collection is “OLD CART” (Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing, Severity).
Nursing diagnosis:
It is the clinical judgment of patients’ actual or potential health problems that a nurse is licensed to treat. Most nursing diagnosis follows the PES format, which means.
- P (Problem): What is the issue? For example, in effective airway clearance.
- E (Etiology): What are the related factors of the issue or why it is happening, for example, excessive mucus production.
- S (Signs/ Symptoms): How do you know it is happening, e.g., the sound of wheezing, coughing, etc.
What are the types of nursing diagnosis?
There are 3 types of nursing diagnosis:
- Actual nursing diagnosis: The problem that is actually present, such as pain.
- Risk diagnosis: Problems that may develop in the future, such as infection.
- Health promotion diagnosis: Patient readiness to improve health.
How is a nursing diagnosis different from a medical diagnosis?
The medical diagnosis tells what disease or medical condition the patient has and is primarily the doctor’s responsibility. And the nursing diagnosis is the patient’s response to the disease, such as problems and risks that nurses can address.
For example:
Medical diagnosis: Pneumonia
Nursing diagnosis: Shortness of breath
Planning:
The next step in the nursing process is planning, which turns diagnosis into actionable care. It is the process of setting clear, actionable goals and identifying specific interventions to solve or manage problems. Here are the steps of planning.
Setting goals: Nurses should be setting SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound). For example, patients’ pain will be 3/10 after an hour of administering medication.
Selecting nursing intervention: Actions to take that will help meet the goals. For example, administering pain medications.
Implementation:
It is the phase of the nursing process where the nurses put the care plan into action. Types of implementations are.
Independent interventions: Nurses don’t need a doctor’s orders to perform an intervention, for example, repositioning the patient.
Dependent interventions: Nurses need doctors’ orders to perform interventions, for example, starting IV fluids.
Collaborative interventions: Interventions done with other healthcare team members, for example, respiratory therapy, physical therapy, etc., to achieve the desired goals.
Evaluation:
It is the final phase of the nursing process where the nurse assesses whether the final goals are met or not, and whether there is any need to modify the care plan. Steps of evaluation in the nursing process are:
- Collect the data.
- Compare with goals.
- Analyze the results.
- Revise the care plan.
- Document the findings.
The mnemonic to remember is ADPIE.
Assess – Diagnose – Plan – Implement – Evaluate
What is the purpose of the nursing process?
- It provides patient-centered care.
- Helps nurses to make informed and logical decisions.
- Ensure continuity of care across shifts and settings.
- The nursing process reduces medical errors and improves recovery.
- It also facilitates communication between healthcare teams.
What is the difference between the nursing process and the nursing care plan?
The nursing process is the framework for clinical reasoning and decision making, whereas the nursing care plan is the written document.
What are the five steps of the nursing process?
The five steps are assessment, diagnosis, planning, implementation, and evaluation.
Conclusion
The nursing process is systematic, individualized patient care that has five steps: assessment, diagnosis, planning, implementation, and evaluation. With the help of the nursing process, nurses can make informed decisions and achieve desirable goals.
Achieve your travel nursing goals with SkillGigs and get high-paying travel nursing contracts. Sign up now and start travel nursing with SkillGigs!
