The Nursing Process

The nursing process is a systematic guide to patient-centered care through 5 sequential steps: assessment, diagnosis, planning, implementation, and evaluation.

Retrieved from https://nurseslabs.com/nursing-diagnosis/ on 7th November 2021

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…

Retrieved from https://www.pinterest.ph/pin/611222980657579285/ on 7th November 2021

Nursing Care Plan Template…

Retrieved from https://www.pinterest.com/pin/732679433111887637/ on 7th November 2021

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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