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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