The 5 Steps of the Nursing Process
The nursing process is a scientific method used by nurses to ensure the quality of patient care. This approach can be broken down into five separate steps.
The first step of the nursing process is assessment. During this phase, the nurse gathers information about a patient's psychological, physiological, sociological, and spiritual status. This data can be collected in a variety of ways. Generally, nurses will conduct a patient interview. Physical examinations, referencing a patient's health history, obtaining a patient's family history, and general observation can also be used to gather assessment data. Patient interaction is generally the heaviest during this evaluative phase.
The diagnosing phase involves a nurse making an educated judgment about a potential or actual health problem with a patient. Multiple diagnoses are sometimes made for a single patient. These assessments not only include an actual description of the problem (e.g. sleep deprivation) but also whether or not a patient is at risk of developing further problems. These diagnoses are also used to determine a patient's readiness for health improvement and whether or not they may have developed a syndrome. The diagnoses phase is a critical step as it is used to determine the course of treatment.
Once a patient and nurse agree on the diagnoses, a plan of action can be developed. If multiple diagnoses need to be addressed, the head nurse will prioritize each assessment and devote attention to severe symptoms and high risk factors. Each problem is assigned a clear, measurable goal for the expected beneficial outcome. For this phase, nurses generally refer to the evidence-based Nursing Outcome Classification, which is a set of standardized terms and measurements for tracking patient wellness. The Nursing Interventions Classification may also be used as a resource for planning.
The implementing phase is where the nurse follows through on the decided plan of action. This plan is specific to each patient and focuses on achievable outcomes. Actions involved in a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient or performing necessary medical tasks, educating and instructing the patient about further health management, and referring or contacting the patient for follow-up. Implementation can take place over the course of hours, days, weeks, or even months.
Once all nursing intervention actions have taken place, the nurse completes an evaluation to determine the goals for patient wellness have been met. The possible patient outcomes are generally described under three terms: patient's condition improved, patient's condition stabilized, and patient's condition deteriorated, died, or discharged. In the event the condition of the patient has shown no improvement, or if the wellness goals were not met, the nursing process begins again from the first step.
All nurses must be familiar with the steps of the nursing process. If you're planning on studying to become a nurse, be prepared to use these phases everyday in your new career.