Nursing Process

• The nursing process is a systematic, rational method of planning and providing individualized nursing care.
• The purposes of the nursing process are to identify a client’s health care status, and actual or potential health problems, to establish plans to meet the identified needs, and to deliver specific nursing interventions to address those needs.
• The nursing process is cyclical and its components follow a logical sequence, but more than one component may be involved at one time.
• At the end of the first cycle, care may be terminated if goals are achieved, or the cycle may continue with reassessment, or the plan of care may be modified.
• The nurse involves the patient, family, other healthcare providers, and environment, as appropriate, in holistic data collection.
• The nurse prioritizes data collection activities based on the patient’s immediate condition, or anticipated needs of the patient or situation.
• The nurse uses analytical models and problem-solving tools in data collection.
• The nurse collects data in a systematic and ongoing process.
• The nurse documents relevant data in a retrievable format.
• The nurse uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data.
• The nurse synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances.
• Assessing in the nursing process involves collecting, organizing, validating, and documenting client data to establish a database about the client’s response to health concerns or illness and the ability to manage health care needs.
• The registered nurse in nursing collects comprehensive data pertinent to the patient’s health or situation.
• Nursing emphasizes “diagnosis and treatment of human responses” based on “accurate client assessments,” including how effective nursing interventions are “to promote health and prevent illness and injury.
• Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses and advocacy in the care of individuals, families, communities and populations.
• Evaluating in nursing involves measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement.
• Implementing nursing interventions involves carrying out or delegating planned nursing interventions and documenting the care provided.
• Developing an individualized care plan in nursing involves specifying client goals/desired outcomes, related nursing interventions, and prioritizing these goals/outcomes in collaboration with the client.
• Planning in nursing involves determining how to prevent, reduce, or resolve identified priority client problems; supporting client strengths; and implementing nursing interventions in an organized, individualized, and goal-directed manner.
• Diagnosing in the nursing process involves analyzing and synthesizing data to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions.
• Planning in the nursing process involves prioritizing problems/diagnoses, formulating goals/desired outcomes, selecting nursing interventions, and writing nursing interventions.
• Implementing in the nursing process involves reassessing the client, determining the nurse’s need for assistance, implementing the nursing interventions, supervising delegated care, and documenting nursing activities.
• Evaluating in the nursing process involves collecting data related to outcomes, comparing data with outcomes, relating nursing actions to client goals/outcomes, drawing conclusions about problem status, and continuing, modifying, or terminating the client’s care plan.
• Nurses use the nursing process as their framework for providing safe, effective, and quality care.