The nursing process is one of the very first concepts I remember learning in nursing school. It’s an easy concept to grasp which is great because it is the foundation of what nurses do (hence the term “nursing process”).
The nursing process will eventually become second nature to you once you begin taking care of patients in the clinical setting as well as creating care plans for those patients. You will ultimately perform this process without even thinking about it!
In a nutshell the nursing process goes like this: You assess your patient and note any abnormalities or issues. You then diagnose your patient with a problem based on the issues you found. You then plan what you are going to do to help resolve said issues. Then you implement those plans, followed up by evaluating how well the plan worked.
It really is that simple. However, there is some terminology that your nursing instructors will want you to be familiar with and they will want you to be able to identify the five steps of the nursing process and what is involved in each step.
A good way to remember the five steps of the nursing process is to use the common acronym ADPIE.
Assessment
Diagnosis
Planning
Implementation
Evaluation
It is important to note that this process is cyclical. You do not simply follow the constituent parts as steps to reach an end. You continue to cycle through the steps as you care for your patient.
Let’s get into the meat and potatoes!
Assessment
Appropriately so, we begin the nursing process by assessing our patient and their situation. The best way to gather assessment data is by doing a head-to-toe assessment. This is useful in obtaining as much information as you can about an individual. This assessment will be based on all your senses (except for taste, thankfully).
What does your patient look like? What do you see when you look at your patient?
What does your patient sound like? What do you hear when you auscultate lung, heart, and bowel sounds?
What does your patient smell like? Don’t go poking your nose in unusual places but take note of any abnormal aromas during your assessment.
What does your patient feel like? When you palpate do you notice any abnormalities?
Think of yourself as a detective whose goal is to gather as much information as possible during the assessment phase. During your assessment be sure to not focus solely on the physical assessment; pay close attention to the level of consciousness of the patient as well as any mental health issues.
The next step of gathering information is to look at the electronic health record (EHR) and electronic medical record (EMR). Take note of medical and surgical history, abnormal lab values, medication profile, etc.
As previously mentioned, this is a cyclical process, so even though assessment is the “first step” in the nursing process you will continually assess and reassess your patient.
Diagnosis
Once you have completed your full assessment, you will move to the process of “diagnosing” your patient. !! The diagnoses that nurses assign are not medical diagnoses!! We can not diagnose a patient with chronic heart failure (CHF) or kidney disease, for example.
What we do as nurses is diagnose our patient with a problem, and we assign this problem based on the symptoms and associated data that the patient is experiencing. The diagnoses you choose must be based on the actual symptoms that the patient is experiencing!
Nurses utilize what is referred to as a “nursing diagnosis”. These nursing diagnoses are chosen from a list of NANDA-I approved diagnoses. The nursing school that you attend should have required you to purchase a nursing diagnosis handbook that includes NANDA-I approved diagnoses (this book will be your best friend while learning about the nursing process and creating nursing care plans). We use this type of book to ensure that the diagnoses we create are approved and accurate to the individual patient needs.
Planning
Once you have identified what the problems are for your patient, then you can work on creating a plan on how to improve or fix those problems. You will set a goal for the patient for each diagnosis you have identified and then you will choose nursing interventions that will help you achieve those goals.
The interventions that you choose to implement will guide the care that you provide for your patient, so they must be relevant and appropriate for the individual. These nursing interventions will require you to use nursing judgement and critical thinking skills.
This is where nursing care plans really come into play, so stay tuned for an upcoming, in-depth guide to nursing care plans.
Implementation
Now that you have created a plan for how to help your patient it is time to put that plan into action!
This is the time to implement the nursing interventions that you felt were appropriate for your individual patient.
Evaluation
The “final” step of the nursing process is the process of evaluation. You will review the effectiveness of the plan you created by evaluating the progress you made toward your goals. You reassess your patient to determine if there were any improvements in their condition.
You identify goals as being “met”, “partially met”, or “not met” based on your reassessment. It is ok if patients do not meet all the goals that you set for them! We can not fix all problems and sometimes it takes longer to fix a problem that you originally predict.
Once you evaluate the effectiveness of the plan you created, you can then revisit any areas that need to be modified. If a problem has been completely resolved then you can remove it from your list of active issues. If interventions that you implemented had no effect on a problem, then you will want to create an updated and revised plan on how to deal with that issue.
You likely now see how this process is cyclical as well as how many of the steps are intertwined with each other. It’s an intuitive process that will, again, become second nature. This process will guide your nursing practice as well as your ability to create nursing care plans.
I hope this was helpful. Give me a holler if you have any questions regarding this material.
Happy Nursing!