6.5: Fundamentals of Nursing Process I

The nursing process is the core of practice for every registered nurse to deliver holistic, patient-focused care. The following are the five steps in the nursing process.

1. Assessment: A nurse uses an organized, dynamic way to collect and analyze data about the patient. It includes the patient's physiological data and psychological, sociocultural, spiritual, economic, and lifestyle factors.
2. Diagnosis: A clinical judgment about the patient's condition and their reaction toward actual or potential health issues and needs is made. The diagnosis considers not only the patient's problem but defines the consequences of the problem to the patient and family.
3. Planning/Outcomes: Depending on the assessment and diagnosis, the nurse decides quantifiable and attainable short- and long-range goals for the patient using the mnemonic SMART that elaborates as specific, measurable, attainable, relevant, and timely.
4. Implementation: The nursing care is executed according to the care plan, ensuring continuity of care for the patient during the hospital stay and discharge.
5. Evaluation: The patient's health condition and the effectiveness of the nursing care are regularly evaluated and modified depending on the outcomes that are met or not met.

The nursing process is one of the specific critical thinking competencies. It is an evidence-based approach to care that nurses use for delivering care, fostering human functions, and responding to health and illness.

The purposes of the nursing process are:

To identify a patient's health status and health care needs.

To execute plans to meet the identified needs.

To deliver need-based nursing interventions.

To protect nurses from accusations related to nursing care.

There are five steps in the nursing process: assessment, diagnosis, planning, implementation, and evaluation.

Nursing assessment is the orderly collection, organization, validation, and documentation of data.

Nursing diagnosis includes interpreting the assessed data and identifying the patient's actual problem.

Planning is formulating patient goals and making blueprints of the interventions required to prevent, reduce, or eliminate health problems.

Implementation consists of performing and documenting the nursing activities.

Finally, evaluation is a planned, ongoing, purposeful activity in which the nurse determines the patient's progress towards achieving goals. It also determines the effectiveness of the nursing care plan.