The nursing process is a systematic guide to patient-centered care through 5 sequential steps: assessment, diagnosis, planning, implementation, and evaluation.
Characteristics of the Nursing Process
- Dynamic & Cyclic – a process in which each phase interacts with and is influenced by the other phases
- Open & Flexible – easily adaptable to different circumstances and emergencies
- Universally Acceptable – allows nurses to practice nursing with all individuals within any type of practice setting
- Patient Centered -the nursing process approach requires care respectful of and responsive to the individual patient’s needs, preferences, and values; the nurse functions as a patient advocate, enables the patient to make informed decisions, and maintains patient-centered engagement within the healthcare setting
- Problem Oriented – aims to tackle arising and possible problems
- Interpersonal & Collaborative – provides the basis for the therapeutic process in which the nurse and patient respect each other as individuals, both of them learning and growing due to the interaction
- Systematic – has an ordered sequence of activities, each of which depends on the accuracy of the activity that precedes it whilst influencing the activity following it
- Goal Directed – the interaction between the nurse and the patient is based on a common goal
- Planned – provides a basic structure on which nursing care can be provided
- Holistic – takes into account all aspects of the patient
Benefits of the Nursing Process
- Improves the patient’s quality of care
- Promotes active patient participation in own health through continuous evaluation
- Promotes nursing efficiency through better time and resource use
- Saves time and energy through the creation of a care plan to follow up with
- Reduces omissions and duplications
- Acts as a guide outlining consistent and responsive care
- Helps in identifying the patient’s goals and required strategies
- Promotes collaboration in the management of the patient’s health-related problem
- Promotes positive patient outcomes
- Promotes patient safety
- Promotes patient satisfaction
Step 1: Assessment
- collect and document data on the patient’s health status
- identify the patient’s strengths as well as limitations
- repeat continuously throughout the nursing process
Step 2: Diagnosis & Planning
- sort and analyze data collected on assessment
- identify actual, potential, or health promotion nursing diagnosis
- put together a nursing care plan tackling identified diagnosis
Step 3: Implementation
- implement the nursing care plan with the aim of achieving the required goals and outcomes
- continue carrying out assessments evaluating the patient’s response to treatment and care
- modify where necessary
- document
Step 4: Evaluation
- perform at specific intervals and continue until patient achieves health goals or is discharged
- target the restoration of self-care abilities if required
- assess the client’s response to the carried out nursing interventions
- assess response to goals and/or planned outcome criteria documented in the Diagnosis phase
- determine the patient’s progress towards aimed goals and the effectiveness of the nursing care plan being carried out
Nursing Care Plan Example…
Nursing Care Plan Template…
NOTE: While it is still being barely done, it is a great idea to implement the Nursing Process into your nursing documentation, including the words Assessment, Diagnosis, Planning, Implementation, and Evaluation.
Nursing Plan Examples based on the Nursing Process
Scenario: Patient Presenting with Hypothyroidism
- Risk of Malnutrition
ASSESSMENT:
- assess how hypothyroidism is currently being controlled
- assess patient’s weight
- assess whether the patient is taking enough fibre in her dietary intake so as to prevent constipation
- check BMI and assess whether patient is at risk of obesity
- ask about daily caloric intake
DIAGNOSIS:
- imbalanced nutrition
PLANNING:
- aim for more nutritious lower caloric intake and weightloss or weight maintenance, depending on the patient’s current weight status
IMPLEMENTATION:
- educate patient about the risk of obesity which comes with hypothyroidism
- teach patient the importance of planning meals beforehand
- teach patient the importance of taking frequent smaller meals rather than a big meal
- encourage patient to keep a food diary so all nutritional and caloric intake can be monitored and adjustments may be made
- involve dietitian if necessary, who can help provide meal plans to prevent over-eating
- encourage exercising
- encourage fluid intake
- ensure the patient has a good support system through family or friends who can help by offering support
EVALUATION:
- compare patient weight with previous weight readings
- maintain fluid intake and output charting
- review food diary
- review care plan
- Risk of Constipation
ASSESSMENT:
- ask patient how much stools are being passed and whether constipation is being experienced
DIAGNOSIS:
- constipation
PLANNING:
- aim to reduce constipation, which is a side effect of hypothyroidism
IMPLEMENTATION:
- encourage patient to drink more water
- encourage exercise
- encourage increased fibre intake
- if necessary, a stool softener such as Movicol may be recommended
EVALUATION:
- review situation with the patient
- review care plan
- Possible Lack of Health Literacy about Hypothyroidism
ASSESSMENT:
- talk to the patient and assess health literacy in general and about hypothyroidism
DIAGNOSIS:
- lack of health literacy
PLANNING:
- teach patient about the condition and the importance of medicine compliance for life
IMPLEMENTATION:
- explain in simple terms what hypothyroidism is
- explain that since her body is not producing enough thyroid hormone, this needs to be taken orally
- explain that thyroxine needs to be taken for life, and that it shouldn’t be stopped even if one is feeling well
- explain that follow-ups are very important since clinicians need to ensure that a therapeutic dose of thyroxine is achieved and maintained
EVALUATION:
- question the patient about the information you have relayed, and ensure that adequate knowledge has been grasped
- re-explain where needed
- Possibility of Fatigue
ASSESSMENT:
- assess patient for fatigue
- if fatigue is being experienced, explain that it is one of the side-effects of hypothyroidism
DIAGNOSIS:
- fatigue
PLANNING:
- aim for better performance during the day and adequate rest during the night
IMPLEMENTATION:
- encourage patient to rest frequently, spacing daily activities throughout the day
- encourage patient to notice at what times it feels easier to maintain activities, so that better day planning can be implemented according to their energy levels
- reassure patient and encourage not to push themselves too much, but to go along with their capabilities
- teach patient that exercise, although may feel too tiring, helps in muscle build-up and strength
EVALUATION:
- assess if patient is feeling better with regards to fatigue
- re-evaluate care plan and adjust where necessary
- Patient Prone To Feeling Cold
ASSESSMENT:
- ask if patient is feeling cold often, and check whether any skin issues are arising due to coldness
DIAGNOSIS:
- patient feeling cold
PLANNING:
- aim for better clothing options/planning and advise regarding skin breakdown
IMPLEMENTATION:
- encourage patient to always carry with an extra jumper or jersey, and to avoid going out when it is very cold or late in the evening if possible
- teach patient to prevent skin breakdown by encouraging use of soap for sensitive skin and adequate skin care
EVALUATION:
- re-assess situation
- re-evaluate care plan and adjust if necessary
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Claire Galea is a mum of three currently in her final year following a Degree in Nursing at the Faculty of Health Sciences, University of Malta, as a mature student.
Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing.
Claire aspires to continue studying following completion of her Nursing Degree, because she truly believes in lifelong education.
Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing.
Claire aspires to continue studying following completion of her Nursing Degree, because she truly believes in lifelong education.
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