What is the nursing process? (Definition and steps)
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Nurses are key providers of medical care and often fulfil an important part in the overall healthcare process. By following the nursing process, you can help ensure a high standard of care for your patients while minimising danger and discomfort. Following the systematic nursing process, you can also make sure that you are performing your complex job professionally, without fear of missing important information or action. In this article, we look at the nursing process and help you apply it effectively in your work.
What is the nursing process?
The nursing process is a model broken into five distinct phases that guides nurses in the way they perform their duties. This model can make it easier for you to think about your patient's needs holistically, helping you to provide a high standard of medical care while considering the patient's health overall. The process is sequential and guides you through the important steps, ensuring you don't miss important details that might affect the patient's treatment protocol or overall health outcomes.
The nursing process can help a nurse plan and prioritise tasks. Like other decision cycles processes, the sequence of steps also applies to planning individual actions during longer periods, like an entire nurse's shift. The process serves as a model for determining a patient's needs, prioritising tasks, performing specific steps in administering care and following up after treatment. As nurses gain more experience, the nursing process might come more naturally when administering patient care. Here's a closer look at the five phases of the nursing process:
The first step of the nursing process is assessment, where you collect the patient's history and look at the objective and subjective data so you can better understand the patient's condition. There are several sources of information you can reference in your assessment, including the patient's chart, existing health documentation and their patient history taken during admission. Depending on the condition of the patient, you may also have access to their instrument readouts and records. Patient's personal reports and the observation notes of other nurses and medical staff can also be useful resources.
A key component of the assessment phase is gathering and juxtaposing all the information available to you to understand whether the patient is improving or deteriorating. An important idea is looking for inconsistencies in the patient data. Finding a symptom that doesn't align with the overall expectation of the patient's condition can provide an early warning to serious underlying conditions. Your nursing assessment starts before you see the patient, but continues throughout the shift. If the physician were to ask you if the patient looked worse than before, you could provide the details you gathered during your nursing assessment.
What do nurses look for during a patient assessment?
A nurse routinely gathers the following information by interviewing the patient to reach a holistic idea of the patient's condition:
Onset of the complaint or symptoms
Location of symptoms like pain or discomfort
Duration of the issue or complaint
Characteristics of the complaint, for example, the type of pain or sensation
Aggravating conditions or factors that make the condition more uncomfortable
Relieving factors or conditions that relieve discomfort of the symptoms
Treatments that are ongoing or completed recently
Related: How to become a nurse practitioner
The next phase after assessment is diagnosis. Using your understanding of the patient's health from the assessment phase, you can work to arrive at a judgement about the patient's current health state. As a nurse performing the diagnosis, you are seeking to link the defining characteristics, risk factors and observed change in a patient's condition. By evaluating the information available, you can help you turn individual patient details into a coherent explanation of their disease or ailment. A nursing diagnosis is separate from the medical diagnosis and might be subjective because it's based on your nursing judgment.
Nursing diagnoses can differ from a physician's diagnosis because they seek to identify root causes and help provide an actionable plan that meets the immediate needs of the patient. If the medical diagnosis is a particular disease, the nursing diagnosis might be an assessment of how the patient is responding to their treatment or a determination of how best to relieve the discomfort or other symptoms that the patient's feeling. For the duration of their treatment, the same patient might receive multiple nursing diagnoses while their condition changes.There are four general categories of nursing diagnoses:
Problem-focused diagnosis: This type of diagnosis identifies specific issues for the patient, like hypothermia, sleep deprivation or dehydration.
Risk diagnosis: Risk diagnoses identifies human responses to health conditions, like the risk of shock.
Health promotion diagnosis: The diagnosis type identifies the patient's ability to engage in a wellness-promoting activity.
Syndrome diagnosis: Syndrome diagnosis, or a medical judgment, describes a cluster of nursing diagnoses that occur together, such as relocation stress syndrome.
The planning phase of the nursing process is where a nurse prepares a strategy for promoting the patient's health or reducing negative symptoms. Make your goals for the patient or the shift during this phase and create a plan of action that allows you to achieve your intentions for the period. Whether it's administering a particular therapy or simply monitoring the patient's condition for signs of change, these plans are typically short term and oriented towards improving the patient's condition incrementally.
Nurses typically set achievable, time-bound and action-oriented goals. While your goals might look unique depending on your nursing style or individual patients' needs, try to keep them realistic and doable during short time frames. The goals many nurses set typically look to achieve fast improvements in their patient's conditions and well-being. By observing the patient's response to the treatment and whether the intervention achieved the goal, a nurse can help generate more information about the patient and make it easier to begin again with the assessment phase of the process.
The implementation phase is when you, as a nurse, follow your plan, administering treatments or interventions in order to achieve the goals you set for yourself. These may involve giving the patient medication and performing minor medical procedures. These could also include smaller steps like actively monitoring blood sugar or oxygen saturation of the patient throughout the day.
With the help of other members of the medical team, nurses can inform other care team members about the patient's behaviour, reactions to treatment and their own nursing assessments. This information can help promote high levels of patient care and improve communication between team members.
After administering the planned interventions, nurses can assess the effectiveness of their treatments and processes in the evaluation phase. By measuring the results through quantifiable metrics like blood oxygenation or sugar levels, you can provide an evidence-based assessment of the efficacy of the intervention. While you might not always have access to empirical data, secondary measures like observation or patient interviews are also key to understanding important changes in a patient's condition. The results of the evaluation phase can drive the next cycle of the nursing process, because care teams can reuse the information from the first cycle.
Are there alternatives to the nursing process?
Many nursing practitioners widely accept the nursing process as an industry standard, but there are alternative processes you can use for patient care. One of these alternatives is the Clinical Judgment Measurement or (CJM) model. Proponents of this model appreciate the process's emphasis on identifying symptom cues. While the phases in the CJM model appear similar to the nursing process steps, there are key differences in the responsibility nurses have to identify relevant cues successfully.
This model comprises the following steps:
How do I become a nurse?
An aspiring nurse needs to complete a nursing educational programme at an approved educational institution that meets regulatory standards. During an educational programme, aspiring nurses can learn the key skills and gain the experience necessary to provide a high standard of medical care to their patients. Among these skills is the nursing process, which nurses learn to apply in training and continue to use throughout their career. A typical training programme for a nurse lasts three years and includes a significant amount of practice in real-world care facilities interacting with patients.
Degree apprenticeships can also be a viable way for an aspiring nurse to fulfil their certification requirements. In this training scheme, you would start a job with a medical facility and spend part of your work time studying with an accredited educational institution. Nurses who have received their education abroad can sometimes use their training for credit with an approved learning programme. Aspiring nurses with prior experience, including practice-based learning, may receive up to 50% credit towards their educational requirements.
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