While nurses have different specializations and work in various environments, one approach remains the same: the nursing process. First defined in 1958, the nursing process is the core element that works to provide the most holistic patient-focused care. Nurses use this model alongside evidence-based practice (EBP) recommendations, critical thinking, and, most importantly, their nurses’ intuition.
Each of the five phases within the process form an accurate picture of assessing and treating a patient. Here’s how the nursing process works.
Nursing Process Phase 1: Assessing
The first step of the nursing process, the assessment stage, requires critical thinking skills and data collection. Assessing the situation involves collecting the patient’s current vital signs and symptoms, known as objective data.
Additionally, subjective data is collected including the patient’s background such as personal and family medical history. This is also the time to document and record the patient’s economic, cultural, spiritual, and lifestyle factors.
If the patient is unable to speak for themselves, the nurse collects the subjective data from a caregiver or guardian. Past health records also assist in the assessment phase’s objective data. All this information together will set the stage for the next step in the process — diagnosis.
Nursing Process Phase 2: Diagnosing
A diagnosis is a nurse’s clinical judgement on a patient’s current or potential health and what the patient’s future needs may be. A nursing diagnosis utilizes Maslow’s Hierarchy of Needs to effectively hypothesize and prioritize patient care decisions.
Developed in the mid-1940’s by Abraham Maslow, this tool helps develop the patient’s proper treatment by starting from the most basic of patient necessities and moving to higher levels for patient fulfillment.
Maslow’s Hierarchy of Needs is understood in five tiers, which are:
Nursing Process Phase 3: Outcome/planning
After the assessment and diagnosis, a plan is created to best treat the patient. The nurse and patient will establish priorities, as well as develop goals and desired outcomes for the patient based on EDP guidelines. Planning comes in three stages: initial planning, ongoing planning, and discharge planning. The goals and desired outcomes will differ slightly depending on which planning stage the nurse treats the patient.
Nursing goals should follow the SMART goal formula:
An example of a simple goal is: “I want to be more compassionate with my patients,” whereas an example of a SMART goal is: “I will spend an extra five minutes getting to know each new patient by asking at least three personal questions so I can talk with them over the duration of their stay.”
Creating goals provides nurses direction in prevention and intervention for their role in the patient’s care. The planning/outcome phase allows for enhanced communication and documentation across the patient’s care plan. Documenting these goals, in tandem with the nurse’s assessment and diagnosis, allows other medical professionals to see the holistic view of the patient’s individual and unique needs. Once the outcome planning stage is complete, the nursing process moves towards action of implementation.
Nursing Process Phase 4: Implementing
This step in the nursing process is when goals and treatment are put into action. It involves ongoing data collection and carrying out planned actions for created goals. During this time, nurses are continuously monitoring the patient’s progress, implementing nursing orders and assessing patient needs depending on their condition. This can also involve direct nursing intervention, including applying a cardiac monitor or oxygen for additional data.
Additionally, the implementation process involves promoting the patient’s self-care, if possible, as well as involving caretakers, guardians, or loved ones in the healing process. Delegation of tasks and determining what is relevant for the patient in the moment using critical thinking skills and nurses’ intuition are also contributing factors for successful implementation.
Nursing Process Phase 5: Evaluating
The last step in the nursing process involves evaluating the patient’s progress and reassessing the desired outcome or SMART goals outlined in the previous phases.
Action steps in the evaluating phase include:
The nursing process is an essential part of holistic patient care. It’s important to take into account each patient’s unique problems and individual care needed to thrive, making the nursing process essential to a patient’s wellbeing.
The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care.
An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.
Outcomes / Planning