Steps of Nursing Process
The nursing process is the application of critical thinking to client care activities.
STEPS OF NURSING PROCESS
Nursing process involves 5 steps which include Assessment, Nursing Diagnosis, Planning , Implementation and Evaluation.
Assessment is the first phase in nursing process. It has 2 sub-phases , Data Collection and Data Analysis. Assessment consist of systematic and orderly collections and analysis of data about the health status of the client for the purpose of making the Nursing Diagnosis.
Such data are obtained via History taking, Observation, physical examination, laboratory data, X-rays and other diagnostic studies.
Any assessment guidelines includes the following:
- Biographical data.
- A health history including family members.
- Subjective and objective data about current health status including physical examination, medical diagnosis and results of diagnostic studies.
- social, cultural and environmental data.
- Behaviors that may place a person at risk for potential disease problems.
Nursing Diagnosis is the second phase of nursing process. A Nursing Diagnosis is a clinical judgement about individual, family or community responses to actual or potential health problems.
Models for these diagnostic statements have been provided by many authors based on the taxonomy developed by NANDA. For most clients, there will be more than one nursing diagnosis.
Nursing diagnostic statements are derived from the nurse’s inferences which are based on the assessed and validated data coupled with nursing, scientific and humanistic concepts and theories.
Planning is the third phase of the nursing process. Planning involves the mutual setting of goals and objectives judging priorities and designing methods to resolve actual or potential problems. Two things are accomplished in the planning phase of nursing process, which includes
- Establishing goals and objectives
- Selection of nursing intervention.
Goals and Objectives
Goals and Objectives which are derived from the nursing diagnosis evolve from and are predicted by the problem portion of the nursing diagnoses. Goals are stated in broad terms to identify effective criteria for evaluating nursing action. Objectives are short statement of desired or expected outcomes of the client.
This is the phase of identification of nursing actions. Nursing interventions evolve from the etiology position of nursing diagnosis. Each nursing action is based on carefully thought out scientific rationale and specifies what kind of nursing care is to be done to meet the clients problems effectively. The nursing care plan deals with actual and potential problems.
Implementation is the fourth phase of the nursing process.Implementation refers to the actions initiated to accomplish the defined goals and objectives. This is the actual giving of nursing care. It is putting plan into action.
The implementation phase begins when the nurse begins to consider various alternative actions and selects those most suitable to achieve the planned goals and objectives. Nursing actions may be carried out by the nurse who developed the nursing care plan or by other nurses or nursing assistants.
Evaluation is the fifth and final phase of the nursing process. It is the appraisal of the client’s appraisal of the client’s behavioral changes that are result of the action of the nurse.
Evaluation consists of the following 5 steps.
- Review the goals or predicted outcomes.
- Collect data about the client’s responses to nursing action.
- Compare actual outcomes to predicted outcomes and decide if goals have been met.
- Record the conclusion.
- Relate nursing plans to client outcomes.