Nursing Process


Article Author:
Tammy Toney-Butler


Article Editor:
Jennifer Thayer


Editors In Chief:
Sherri Murrell


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
7/30/2019 3:25:42 PM

Introduction

In 1958, Ida Jean Orlando started the nursing process that still guides nursing care today. Defined as a systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care.[1][2][3]

Function

The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation.

Assessment

Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.

Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection. Electronic health records may populate data in and assist in assessment.

Critical thinking skills are essential to assessment, thus the need for concept-based curriculum changes.

Diagnosis

The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care.

The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family or community.  

A nursing diagnosis encompasses Maslow's Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate for all individuals. Basic physiological needs/goals must be met before higher needs/goals can be achieved such as self-esteem and self-actualization. Physiological and safety needs provide the basis for the implementation of nursing care and nursing interventions. Thus, they are at the base of Maslow's pyramid, laying the foundation for physical and emotional health.[4][5]

Maslow's Hierarchy of Needs

  • Basic Physiological needs: Nutrition (water and food), elimination (Toileting), airway (suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABC's), sleep, sex, shelter, and exercise.
  • Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation, suicide precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of trust and safety (therapeutic relationship), patient education (modifiable risk factors for stroke, heart disease).
  • Love and Belonging: Foster supportive relationships, methods to avoid social isolation (bullying), employ active listening techniques, therapeutic communication, sexual intimacy.
  • Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of control or empowerment, accepting one's physical appearance or body habitus.
  • Self-Actualization: Empowering environment, spiritual growth, ability to recognize the point of view of others, reaching one's maximum potential.

Planning

The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum.

Goals should be:

  1. Specific
  2. Measurable or Meaningful
  3. Attainable or Action-Oriented
  4. Realistic or Results-Oriented
  5. Timely or Time-Oriented

Implementation

Implementation is the step which involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols and EDP standards.

Evaluation

This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.

Issues of Concern

According to a 2011 study conducted in Mekelle Zone hospitals, nurses lack the knowledge to implement the nursing process into practice and factors such as nurse-patient ratios inhibit from doing so. Ninety percent of study participants lacked sufficient experience to apply the nursing process into standard practice. The study also concluded that a shortage of available resources, coupled with increased workloads due to high patient-nurse ratios, contributed to the lack of the nursing process implementation in the delivery of patient care.[6][7][8]

Clinical Significance

The utilization of the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition.

As explored by Salmond and Echevarria, healthcare is changing, and the traditional roles of nurses are transforming to meet the demands of this new healthcare environment. Nurses are in a position to promote change and impact patient delivery care models in the future.[9][10]

Other Issues

Critical thinking skills will play a vital role as we develop plans of care for these patient populations with multiple comorbidities and embrace this challenging healthcare arena. Thus, the trend towards concept-based curriculum changes will assist us in the navigation of these uncharted waters. 

Concept-Based Curriculum

Baron further explores this need for a concept-based curriculum as opposed to the traditional educational model and the challenges faced with its implementation. A direct impact on quality patient care and positive outcomes. Nursing practice and educational environments form a bond with clinical knowledge and expertise, and that bond facilitates the transition into the current workforce as an indispensable team player and leader in this new wave of healthcare. 

Learning should be the focus and the integration into current practice. Learning is a dynamic process, propelled by a force that must coexist within the same learning milieu between educator and student, preceptor and novice, mentor, and trainee. 

IN the future, nurses must be able to problem solve in a multitude of situations and conditions to meet these new adversities: challenging nurse-patient ratios, multifaceted approaches to prioritization of care, fewer resources, navigation of the electronic health record as well as functionality within the team dynamic and leadership style.


  • Image 6345 Not availableImage 6345 Not available
    Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN
Attributed To: Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN

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Nursing Process - Questions

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The nursing process incorporates certain essential elements to guide client-centered care. Which of the following is not a vital part of the process?



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Which is not a step used in the nursing process?



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What is the third step in the nursing process?



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Which of the following does not represent a form of objective data?



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A 17-year-old male presents to the emergency department with right lower quadrant abdominal pain, nausea, vomiting, and diarrhea for 2 days. His temperature on arrival is 39.4 C, heart rate 132 beats/min, blood pressure 90/40 mmHg, and pain level 8/10. A stool sample you obtain for culture and sensitivity has a foul smell. A urine sample collected is dark, tea-colored, and when measured is 75 mL. Which of the following examples listed does not represent objective data?



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A nurse is caring for a group of clients in the telemetry unit. Being a novice nurse and still in the process of building a clinical knowledge base, the new nurse decides to call the healthcare provider with the below findings to prevent a complication. For which result is the nurse correct in notifying the provider? Select all that apply.



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A nurse is caring for a team of clients and preparing to dispense medications. To carry out this procedure safely after all pertinent assessment data has been collected, what are appropriate actions taken by the nurse? Select all that apply.



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A licensed nurse is working in a telemetry unit and reviewing lab results for her patients. Recognizing abnormal results and the necessary interventions required is paramount to the delivery of safe care. Which lab results listed need further investigation and follow up? Select all that apply.



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A 78-year-old female recently admitted with gastroenteritis arrives on the unit. In the bedside report, the nurse learns the client has received a 1-liter normal saline (NS) bolus in the emergency department and has NS infusing at 500 mL/hr for a second-liter bolus. Her past medical and surgical history includes hypertension, renal insufficiency, and one myocardial infarction 4 years prior with stents. On arrival, her blood pressure is 118/74 mmHg, heart rate 108 beats/min, respiratory rate 18, and pulse oximetry 97% on room air. She is alert, oriented, and pale, and her skin is warm and dry. She has had no diarrheal episodes in 6 hours. She last voided 5 hours before admission and the urine was a dark, tea color. As the primary nurse enters the room to initiate a new IV bag of 1000 mL of NS with 20 meq/KCL at 100 mL/hr, the nurse observes the client is restless, sitting upright, and gasping for breath. Her skin is now cool and clammy, and she has labored respirations at a rate of 48 with an oxygen saturation of 86% on room air. Breath sounds reveal crackles. Her blood pressure is 180/108 mmHg and heart rate 132 beats/min and irregular. Based on this clinical picture, how does the nurse expect the healthcare provider will proceed in managing this client's current condition? Select all that apply.



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A nurse is managing the care of a team of clients with various medical diagnoses. After receiving bedside report, reviewing the prescriptions by the providers, and collecting data from assessments performed, the nurse sets out to deliver care. What orders should the nurse discuss with the healthcare provider before delivering care? Select all that apply.



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A novice nurse is working under the supervision of a preceptor. After receiving bedside report, the nurse proceeds to review all pending orders on their assigned clients. While studying the prescriptions to prioritize care, the nurse recognizes orders for medications that require notification of the attending healthcare provider for clarification as a safety measure. What medication orders listed need provider notification before carrying out the order? Select all that apply.



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Nursing Process - References

References

Karttunen M,Sneck S,Jokelainen J,Elo S, Nurses' self-assessments of adherence to guidelines on safe medication preparation and administration in long-term elderly care. Scandinavian journal of caring sciences. 2019 May 6;     [PubMed]
Younan L,Clinton M,Fares S,Samaha H, The translation and cultural adaptation validity of the Actual Scope of Practice Questionnaire. Eastern Mediterranean health journal = La revue de sante de la Mediterranee orientale = al-Majallah al-sihhiyah li-sharq al-mutawassit. 2019 Apr 25;     [PubMed]
Epstein AS,Desai AV,Bernal C,Romano D,Wan PJ,Okpako M,Anderson K,Chow K,Kramer D,Calderon C,Klimek VV,Rawlins-Duell R,Reidy DL,Goldberg JI,Cruz E,Nelson JE, Giving Voice to Patient Values Throughout Cancer: A Novel Nurse-Led Intervention. Journal of pain and symptom management. 2019 Apr 26;     [PubMed]
Shih CY,Huang CY,Huang ML,Chen CM,Lin CC,Tang FI, The association of sociodemographic factors and needs of haemodialysis patients according to Maslow's hierarchy of needs. Journal of clinical nursing. 2019 Jan;     [PubMed]
Maslow K,Mezey M, Recognition of dementia in hospitalized older adults. The American journal of nursing. 2008 Jan;     [PubMed]
Raso A,Ligozzi L,Garrino L,Dimonte V, Nursing profession and nurses' contribution to nursing education as seen through students' eyes: A qualitative study. Nursing forum. 2019 May 6;     [PubMed]
Hu J,Yang Y,Fallacaro MD,Wands B,Wright S,Zhou Y,Ruan H, Building an International Partnership to Develop Advanced Practice Nurses in Anesthesia Settings: Using a Theory-Driven Approach. Journal of transcultural nursing : official journal of the Transcultural Nursing Society. 2019 May 6;     [PubMed]
Bird M,Tolan J,Carter N, Baccalaureate Nursing Students' Perceptions of Learning in Mentored and Simulated Research Practica. The Journal of nursing education. 2019 May 1;     [PubMed]
Salmond SW,Echevarria M,Allread V, Care Bundles: Increasing Consistency of Care. Orthopedic nursing. 2017 Jan/Feb;     [PubMed]
Rigolosi R,Salmond S, The journey to independent nurse practitioner practice. Journal of the American Association of Nurse Practitioners. 2014 Dec;     [PubMed]

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