The Nursing Process: Fundamentals in Nursing
Updated: Mar 27, 2022
When studying during nursing school or for your NCLEX exam, many questions will be based on the nursing process. It's a good idea to practice many NCLEX practice questions just to get a grasp of what a question is asking.
So what is the nursing process?
The nursing process is a five-step, evidence-based procedure that helps nurses think holistically about their patient's entire picture and treatment strategy. During nursing school, nurses study the nursing process and utilize it informally when caring for patients in a professional context. Here are the five steps of the nursing process.
The first step in providing nursing care is for an RN to gather and evaluate data about a client in a systematic, dynamic fashion. Not only physiological data is considered, but also psychological, social, spiritual, economic, and lifestyle variables.
A nurse's assessment of a hospitalized patient in pain, for example, includes not only the physical causes and manifestations of pain, but also the patient's response—inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or a request for additional pain medication.
The nurse's clinical judgment regarding the client's response to real or anticipated health issues or requirements is the nursing diagnosis.
The diagnosis reflects not only that the patient is in pain, but also that the pain has produced additional issues such as worry, poor nutrition, and family strife, or that the pain has the potential to develop complications—respiratory infection, for example, is a risk for an immobile patient.
Major Takeaway: The nurse's care plan is based on the diagnosis.
3. Planning / Outcomes
The nurse sets measurable and achievable short- and long-term goals for this patient based on the assessment and diagnosis, such as moving from bed to chair at least three times per day, maintaining adequate nutrition by eating smaller, more frequent meals, resolving conflict through counseling, or managing pain with adequate medication.
The patient's assessment data, diagnosis, and objectives are documented in the patient's care plan, which is accessible to nurses and other health professionals caring for the patient.
Nursing care is provided in accordance with the care plan, thus the patient's care must be consistent throughout his or her stay in the hospital and as he or she prepares to be discharged. The patient's care is noted in the medical record which is known as documentation.
The patient's condition as well as the efficacy of the nursing care must be assessed on a regular basis, and the care plan adjusted as needed.
Why is the nursing process essential to know?
Every day decision–making is influenced by the nursing process.
It becomes second nature over time, and some people refer to it as their "nurse brain."
Nurses can analyze a situation, identify what's going on, adjust plans, and execute protocols on the fly thanks to the nursing process. Because a patient's condition might change at any time, nurses must use the nursing process to make quick choices and provide the best possible care.
Adjustments will almost always be necessary, thus nurses must be ready to adapt to any minor change. Nurses are experts at anticipating the unforeseeable.
Ready to test your knowledge? Take a quiz!