The Nursing Process

The nursing process is a systematic way a nurse decides how to treat the patient's responses to health and illness. There are five steps in the nursing process:

1. Assessment

2. Diagnosis

3. Planning

4. Intervention/Implementation

5. Evaluation

Assessment is data collection. During the assessment step, the nurse is gathering subjective and objective data from the patient that will later be used to arrive at a nursing diagnosis. Subjective data is information that is reported by the patient such as, "I'm feeling warm." Objective data is information that can be measured or observed, such as the patient's temperature or the color of the patient's skin.

Diagnosis is the patient's problem, which is determined by analyzing data collected during the patient's assessment. The data could lead the nurse to determine that the patient has more than one problem. This diagnosis is referred to as a nursing diagnosis. A nursing diagnosis is different from a medical diagnosis. For example, a nurse might diagnose an alteration in mobility in a patient who has had a stroke. A physician or advanced nurse practitioner determines the medical diagnosis, which is cerebral vascular accident (CVA). The nurse might also determine this patient has a potential for alteration in nutrition because he or she is having difficulty swallowing because of the stroke.

The plan is how the nurse proposes to treat the nursing diagnosis. The plan takes the form of a care plan that itemizes the patient's nursing diagnosis. Each nursing diagnosis will have an expected outcome or goal. The care plan contains at least one nursing intervention for each nursing diagnosis, the expected outcome for each intervention, and how the nurse will evaluate the outcome. For example, the final outcome goal for an alteration in mobility might be to have the patient get out of bed and ambulate without assistance. However, the interventions will begin with getting the patient out of bed and to the chair or assisting the patient to walk short distances each day.

The intervention is executing the plan. For example, the nurse will assist the patient to the chair the first time and might delegate the task to a nursing assistant thereafter if the patient does not have any problems.

The evaluation step of the nursing process determines if the intervention worked. For example, the nurse evaluates the patient's response to getting out of bed and also determines if the patient continues to get out of bed on a daily basis. If the patient continues to have no problems getting out of bed, the nurse may change the interventions to include walking short distances in addition to getting out of bed and increase those distances each day. When the patient is able to get out of bed and walk without assistance, the final goal will have been achieved.

The nursing process is circular. If the nurse determines during the evaluation step that the intervention didn't work or the expected outcome has been achieved, the nurse begins the nursing process again, starting with the assessment step and then revises the care plan as the patient's problem changes. The nursing process is repeated until the patient's problem(s) is resolved.

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