Nursing Process Overview

Nursing Process

• The nursing process is a systematic approach to patient care that involves five steps: assessment, diagnosis, planning, implementation, and evaluation.

Assessment

• Involves gathering data about a patient's current health status and any potential problems.

Diagnosis

• Focuses on identifying patient problems
• There are two types of problems:
  • Nursing Diagnoses: Actual or potential health problems that nurses can manage through independent interventions.
  • Collaborative Problems: Physiologic complications for which nurses need to monitor for changes and work with other members of the healthcare team to intervene.

Planning

• Developing goals and a comprehensive care plan to address diagnosed problems and achieve desired patient outcomes.
• Key steps in planning:
  • Prioritize problems
  • Formulate goals and desired outcomes
  • Select nursing interventions
  • Write nursing interventions

Implementation

• Carrying out the care plan through nursing interventions.

Evaluation

• Determining the patient's response to interventions and the extent to which the desired outcomes have been achieved.
• Evaluation can lead to continuing, modifying, or terminating the care plan.

Flow of the Nursing Process

• The nursing process is a cyclical process where the evaluation step can lead back to any of the previous steps, depending on the patient's needs.