Nursing Process: A 5-Step Guide

• The nursing process is used to deliver nursing care to the client.
• The nursing process is a systems approach and is used to develop nursing care.
• The nursing process involves a five-step process.

The Five Steps of the Nursing Process

• Assessment: A systematic collection of data to determine a client's health status. Data sources include the patient, family, and previous healthcare providers.
• Diagnosis: Analyzes assessment data to determine key issues and make clinical judgements.
• Planning: Creation of a formal plan that prescribes strategies and alternatives to attain expected outcomes.
• Implementation: Providing health teaching, medications, and therapy.
• Evaluation: Evaluation of patients response to the implementations via labs, testing, and visual.

Subjective vs Objective Data

• Subjective data are patients verbal descriptions of their health concerns, usually obtained during a health history or questioning, including feelings, perceptions, and self-reported symptoms.
• Objective data consists of observations or measurements of a patient's health status. Example: inspection of a wound, observed behaviour (anxiety, fear), measurements (BP, Body Temp, body weight, height)

Client Interview

• Gather a health history using interview techniques.
• Primary information source is the patient's description.
• Secondary information source is the patient chart (notes, medication records, lab tests), caregivers/significant others.
• A tertiary information source is relevant literature or nurses experiences.
• An organized conversation with the client/requires preparation.
• The nurse introduces themselves and explains their role during the Orientation Phase.
• Establish a caring therapeutic relationship during the Working Phase.
• Gain insight about the client's concerns or worries.
• The nurse and client become partners during the interview
• Allow patient time to ask questions during the Termination Phase.
• Family history is also taken.
• Open-ended questions allow the patient to elaborate freely, such as "Tell me how you are feeling" or "Describe how your partner has been helping you at home."
• Closed-ended questions require a more direct response, such as "Do you feel as if the medication is helping?" or "Are you having pain now?"
• A Physical Exam is also part of the information gathering process.

Nursing Diagnosis vs. Medical Diagnosis

• A medical dx refers to the disease process, is related to the pathophysiology and remains with the client for as long as the disease is present.
• Identification of a disease condition is based on a evaluation of physical signs, symptoms, pt's medical history, and results of diagnostic tests and procedures
• A nursing dx describes the clients' physical, sociocultural, psychological, sexual, and spiritual responses to the illness or health problem. Nursing dx changes as the clients' responses change.
• The clinical judgement is about individual, family, or community responses to actual and potential health problems or life processes that is within the nursing domain (NANDA).

Benefits of NANDA International Nursing Diagnosis

• The nursing diagnosis is an international standard.
• Clinical criteria are objective and subjective signs and symptoms, or risk factors that lead to a diagnostic conclusion
• Nurses learn to recognize patterns of defining characteristics and then readily select the corresponding dx (diagnosis).

Four Types of Nursing Diagnosis

• Actual: Responses to health conditions or life processes that exist in an individual, family, or community, which indicates sufficient assessment data is available to establish the nursing dx.
• Risk: Human responses to health conditions or life processes that will develop in a vulnerable individual, family, or community. Factors include physiological, psychosocial, familial, lifestyle, and environmental components
• Health promotion: Clinical judgement of a person's motivation and desire to increase well-being and actualize health potential.
• Wellness: Level of wellness in a patient that can be enhanced
• The patient wishes to or has achieved an optimal level of health

Goal Setting

• Specific patient behaviours or physiological responses that nurses set to achieve through the nursing diagnosis or collaborative problem resolution.
• Goals can be person-centered, short-term, or long-term.
• Develop a plan of care from a nursing assessment

Selecting Nursing Interventions

• Interventions are not selected at random. Resources are reviewed which include; nursing literature, standard protocols, best practice guidelines, policy and procedure manuals, and textbooks.
• Interventions are ideally evidence-based.
• Consider certain factors when choosing interventions.
• Consider the nursing diagnosis
• Consider goals and expected outcomes
• Consider the evidence base
• Consider feasibility and acceptability
• Consider nurse competence

The nursing process is a systematic approach used to deliver nursing care, involving five key steps. These steps include assessment, diagnosis, planning, implementation, and evaluation. Data collection involves subjective and objective information.