Nursing Process

• Ida Jean Orlando began developing the nursing process in 1958
• According to Orlando’s theory, the patient’s behavior sets the nursing process in motion
• The nursing process functions as a systematic guide to client-centered care with five subsequent phases
• The nursing process is defined as a systematic, rational method of planning that guides all nursing actions in delivering holistic and patient-focused care
• Purposes of the Nursing Process:

  • Identify the client’s health status and actual or potential health care problems or needs through assessment
  • Establish plans to meet the identified needs
  • Deliver specific nursing interventions to meet those needs
  • Apply the best available caregiving evidence and promote human functions and responses to health and illness
  • Protect nurses against legal problems related to nursing care when following the standards of the nursing process
  • Help the nurse perform in a systematically organized way their practice
• • Establish a database about the client’s health status, health concerns, response to illness, and ability to manage health care needs
• • Is a dynamic, cyclical process in which each phase interacts with and is influenced by the other phases
  • Requires critical thinking for identifying client problems and implementing interventions to promote effective care outcomes
• Characteristics of the Nursing Process:

  • Requires care respectful of and responsive to the individual patient’s needs, preferences, and values
  • Functions as a patient advocate by keeping the patient’s right to practice informed decision-making and maintaining patient-centered engagement
  • Provides the basis for the therapeutic process in which the nurse and patient respect each other as individuals
  • Functions effectively in nursing and inter-professional teams, promoting open communication, mutual respect, and shared decision-making
• Assessment:

  • Nurse gathers information about the patient’s health status, including physical, psychological, and social factors using different assessment techniques
  • Data is used to form an accurate diagnosis and develop a care plan
  • Opportunity for the nurse to establish rapport with the patient, build trust, identify patient’s needs, and set priorities for care
• Diagnosis:

  • Nurse uses information gathered in the assessment stage to determine the patient’s health problems
  • Considers all aspects of the patient’s health to make an accurate diagnosis
  • Uses critical thinking and problem-solving skills to determine the underlying cause of the patient’s symptoms
• Planning:

  • Nurse develops a plan of care based on the patient’s health problems and needs, as well as the resources available
  • Involves the patient in the planning process to ensure the plan of care meets their needs and preferences
  • Care plan should be individualized to the patient, taking into account their unique circumstances and preferences
• Implementation:

  • Nurse carries out the plan of care, which may involve administering medications, performing procedures, or providing education to the patient
  • Monitors the patient’s response to treatment and makes necessary adjustments to the care plan
• Evaluation:

  • Nurse assesses the patient’s progress and determines whether the plan of care was effective
  • Makes changes to the plan of care based on the patient’s progress and needs
• Diagnosis involves identifying problems or needs based on assessment findings using the nursing diagnosis classification system.
• Assessment involves gathering data about the client's health status through observation, interview, examination, and testing.
• The nursing process is the systematic approach to planning, implementing, evaluating, and documenting patient care.
• The nursing diagnosis classification system includes three types of diagnoses: actual (problem), risk (potential problem), and outcome (desired result).
• Goals are statements that describe what the nurse hopes to achieve with the patient during the course of care.
• Data is collected from various sources such as family members, friends, healthcare providers, and community agencies.
• Actual diagnoses describe existing conditions that require intervention.
• Risk diagnoses predict potential problems that could occur if not addressed.
• The nurse must consider factors that influence the client's behavior and responses during assessment.
• Objectives are specific actions or steps that will be taken by the nurse to accomplish the goals.
• Outcomes are measurable results that indicate if the objectives have been achieved.
• The nurse must also consider cultural differences when collecting data.
• Actual Diagnoses are used when there is an existing condition that requires intervention.
• Outcome Diagnoses describe what the nurse hopes will happen as a result of interventions.
• Objectives are specific steps taken by the nurse to reach the goals.
• Evaluation assesses whether the desired outcome has occurred.
• Implementation involves carrying out the plan of care.
• Intervention plans include strategies, techniques, procedures, and treatments that address the diagnosis and promote desired outcomes.
• Goals are broad statements that describe what needs to happen as a result of nursing interventions.
• Assessment involves gathering information about the patient's health status through various methods such as interview, observation, physical examination, laboratory tests, imaging studies, and other diagnostic procedures.
• Intervention refers to actions or activities performed by the nurse, patient, family, or other health care providers.
• Intervention refers to actions or activities performed by the nurse, such as administering medications or performing procedures.
• Diagnosis involves identifying problems or issues related to the patient's health.
• The nursing process consists of five steps: assessment, diagnosis, planning, implementation, and evaluation.
• Implementation involves implementing the planned actions and providing appropriate interventions to meet the patient's needs.
• Critical thinking is an essential skill for nurses to effectively implement the nursing process.