One of the most essential roles of a nurse is to provide quality care to patients.
A registered nurse's (RN) licensure determines the services they are qualified and competent to provide. Known as "the nursing scope of practice," this describes the services—actions or behaviors—that a nurse is qualified to provide while on the job. These services should adhere to the ANA Standards of Professional Nursing Practice.
A registered nurse should be familiar with the five-step nursing process, a standard nursing procedure that helps nurses provide planned and organized patient care.
The five-step nursing process is a systematic approach to client-centered care that includes five sequential steps:
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
Nurses can use these steps to create tailored care plans that address each patient's needs.
Want to learn more? Keep reading to learn the five fundamental steps of the nursing process.
What Is The Nursing Process?
The nursing process is a nurse's actions to assess, plan, and deliver care. A nursing process also helps to monitor and evaluate a patient's response to treatment. The nursing process can also be considered a consistent sequence or framework nurses use when assessing and caring for patients. The five steps of the standard nursing process are assessment, diagnosis, planning, implementation, and evaluation. The written representation of the nursing process is called a nursing care plan (NCP).
However, over time, some nursing processes have evolved into six components, which may also include outcome and identification. For this reason, some people use the acronym ADOPIE to remember the ANA Standards and the nursing process, with each letter representing six components of a nursing process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.
1. Assessment
During this first step of the nursing process, nurses collect information about the patient's health, medical history, and current condition.
Why is Patient Assessment Important?
A comprehensive assessment allows nurses to identify the patient's needs, problems, and potential risks. This information serves as the foundation for developing an individualized care plan.
2. Diagnosis
During this second step of the nursing process, nurses analyze the assessment data to determine the patient's actual and potential health problems.
Why is Nursing Diagnosis Important?
Proper diagnosis enables nurses to focus on the patient's specific needs and create effective interventions.
3. Planning
Once a nursing diagnosis has been identified, a nurse creates a care plan. During this third step of the nursing process, nurses may collaborate with the patient, their family, and the healthcare team to establish goals and determine the most effective interventions.
Why is Planning Important?
Planning is crucial because it aids in establishing person-centered goals and helps to prioritize the needs of the client.
4. Implementation
During this fourth step of the nursing process, nursing interventions are prioritized, patient safety is evaluated, and all interventions are documented. Implementation entails implementing interventions, administering medications, and providing education and support.
Why is Implementation Important?
Implementation is important because it puts the treatment plan (NCP) into effect and helps achieve predetermined goals and track progress toward specific outcomes.
5. Evaluation
This final step of the nursing process involves evaluating the patient's response to the implemented interventions and assessing whether the desired outcomes have been achieved. The care plan should be altered if the desired outcomes are not achieved or are only partially achieved by the indicated time frame.
Why Is Evaluation Important?
Data collected during evaluation helps determine the effectiveness of the care provided. Evaluation also helps ensure patient safety by identifying potential complications or adverse treatment reactions.
Why Is The Nursing Process Important as a Whole?
Having a standardized nursing process is important because it emphasizes care centered around the individual patient. For example, a nursing care plan for a generalized fever will differ from a nursing care plan for dengue fever. Furthermore, a nursing care plan that addresses a high fever in a child will be different from an NCP that aims to help an adult suffering from a fever.
Essentially, the five-step nursing process—assessment, diagnosis, planning, implementation, and evaluation—enables nurses to assess the patient's needs and make precise diagnoses accurately. A nursing process also ensures that necessary nursing interventions are implemented, helping patients receive superior care at all times.
Nursing Process Examples
There are five steps in a typical nursing process. These steps will create an effective care plan to help patients receive thorough, individualized, high-quality care. While a nursing care plan will vary depending on the nursing diagnosis, the following is an example of what nursing plans may look like:
Patient: John Doe
Nursing Care Plan by: Nancy Nurse
Nursing process examples include collecting relevant data about a patient and planning and implementing appropriate interventions. From there, the nurse can assess the outcomes to determine which interventions were effective and which were not. An NCP can be revised to accommodate and treat a patient differently if necessary.
How To Create a Tailored Nursing Plan For Your Patient
Working as a registered nurse will require you to develop personalized nursing plans (NCPs) for your patients regularly. This is because an NCP is a way to set reasonable goals and track the progress of a patient and their care, often on a live document.
Some healthcare technology and medical charting tools are used with computerized nursing plans. Digital nursing plans can replace traditional paper forms, and converting them to digital format makes the task or process more efficient and faster. However, it is still essential to remain familiar with writing a nursing plan on standard paper format just in case.
Here are some quick tips for developing a personalized nursing plan for your patient:
- Personalize interventions for patient assessment, such as medication administration, wound care, or patient education.
- Prioritize planning and outcome nursing steps by setting clear, attainable goals. SMART goals are what nurses should aim for (Specific, Measurable, Attainable, Realistic, and Time-Oriented).
- Collaborate with other healthcare members to identify optimal nursing interventions.
- Evaluate and reassess the nursing care plan regularly and modify the care plan as needed to ensure optimal patient outcomes.
Ensure the Best Outcomes For Your Patients
Nursing has many responsibilities but can be among the most rewarding healthcare careers. So, while becoming adept in the nursing process and creating nursing care plans may seem overwhelming initially, this process ensures that your care as a nurse is effective, patient-centered, and of the highest quality.
Ultimately, nurse care planning ensures that all aspects of the patient's care are considered and provides a roadmap for comprehensive care. The nursing process can also help nurses feel confident in providing compassionate, tailored, and individualized patient care. Also, by integrating evidence-based practice, nurses can continuously improve the quality of care they give to their patients.
Are you still looking to know more about the nursing process? For more information and examples of general nursing plans, see our guide, What Is a Nursing Care Plan? The Ultimate Guide to NCPs.
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