The Nursing Process

By Kathy Quan RN BSN PHN

The nursing process is based on a nursing theory developed by Ida Jean Orlando. She developed this theory in the late 1950's as she observed nurses in action. She saw "good" nursing and "bad" nursing. From her observations she learned:

* The patient must be the central character

* Nursing care needs to be directed at improving outcomes for the patient; not about nursing goals

* The nursing process is an essential part of the nursing care plan

Not As Complicated as it Seems
The nursing process is really not as complicated as it seems. It consists of basically five steps. Originally, Ms. Orlando had four, but through practical application over the past 40 years, one step evolved into two and now there are five. All nursing personnel take part in the nursing process. The RN has the primary responsibility however.

The Five Steps

* Assessment
* Diagnosis
* Planning
* Implementation
* Evaluation

Assessment
This is the data collection step. For RNs it also entails analyzing the data and possibly making a more complex and in-depth assessment based on the findings. LPNs, CNAs and all non-licensed nursing personnel are not trained in analyzing data. This gives rise to statements that "LPNs cannot assess patients". In truth they do asses, they just don't complete the second portion of that step; analysis. They may not make any independent decisions about the patient's plan of care. It is important for LPNs as well as CNAs and non-licensed nursing personnel to understand the nursing process, but to also understand and adhere to their job description and/or scope of practice.

Assessment involves taking vital signs, performing a head to toe assessment, listening to the patient's comments and questions about his health status, observing his reactions and interactions with others. It involves asking pertinent questions about his signs and symptoms, and listening carefully to the answers.

Once you have collected the data, the process moves on to analysis of the data to determine the health status, the patient's coping mechanisms or lack thereof, his ability to use these mechanisms and to identify his problems related to his health status.

Diagnosis
Nurses only make nursing diagnoses, except in the case of Nurse Practitioners who have been trained and licensed to make medical diagnoses. Once you have identified the patient's problems related to his health status, you formulate a nursing diagnosis for each of them. You will also prioritize the problems in formulating your plan and goals.
The nursing diagnoses are categorized by a system commonly referred to as NANDA. The North American Nursing Diagnosis Association (NANDA) has now become an international group who works to classify nursing diagnoses, and to review and accept new diagnoses as needed.

In 2000, NANDA adopted the current classification system (known as a taxonomy) as Taxonomy II. There are 13 domains which are subdivided into 106 classes and 155 nursing diagnoses.

The RN chooses a nursing diagnosis from the NANDA list which most closely describes the patient's problem related to his health status. This might be a current problem or a potential problem which needs to be addressed. It can even be a problem that relates to his family rather then to him alone such as the family's inability to cope with life style changes necessitated by the patient's illness.

In fact, most patients will have more than one problem to diagnose and address. The severity of the problem and how it is effecting patient outcomes will determine the priority for that problem. This priority can change, and the nurse has to adapt to these changes. This is often difficult for students and new nurses to grasp. As they begin to understand and utilize the nursing process, this will become more clear.

Planning
Setting goals to improve the outcomes for the patient is a primary focus of the nursing process. Based on the nursing diagnoses, what are the expectations for this patient? This not about nursing goals. They are patient goals. This is about improving the health status and quality of life for your patient. This is about what your patient needs to do to improve his health status and/or better cope with his illness.

Planning also involves making plans to carry out the necessary interventions to achieve those goals. The use of formal care plans or care maps and protocols is highly advised.

For example: "after instruction insulin therapy, the patient will successfully return demonstrate the ability to accurately draw up the insulin by Monday and safely self inject by Tuesday."

Implementation
Implementation is setting your plans in motion and delegating responsibilities for each step. Communication is essential to the nursing process. All members of the health care team should be informed of the patient's status and nursing diagnosis, the goals and the plans. They are also responsible to report back to the RN all significant findings and to document their observations and interventions as well as the patient's response and outcomes.

Evaluation
The nursing process is an ongoing process. Evaluation involves not only analyzing the success (or failure) of the current goals and interventions, but examining the need for adjustments and changes as well. The evaluation process incorporates all input from the entire health care team, including the patient. Evaluation leads back to Assessment and the whole process begins again.

The Whole Patient
The nursing process involves looking at the whole patient at all times. It personalizes the patient. He is Mr. Jones, not "the CVA in 214B." It also forces the health care team to observe and interact with the patient, and not just become the task they are performing such as a dressing change (the dressing change in 317A), or a bed bath. In so doing, the process provides a roadmap that ensures good nursing care and improves patient outcomes.

Most Misunderstood Theory
The nursing process is perhaps one of the most misunderstood nursing theories, and yet one of the most effective as well as practical. Many students struggle with this theory. It takes time for students and new nurses to get the hang of this process, and many fight it every step of the way, until one day a light bulb begins to burn brightly. The nursing process is used to help nurses make nursing care plans, carry them out and improve patient outcomes.