The Nursing Process (2024)

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.

Assessment
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.

Diagnosis
The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse’s care plan.

Outcomes / Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.

Implementation
Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.

Evaluation
Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.

The Nursing Process (2024)

FAQs

The Nursing Process? ›

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 is the first step and involves critical thinking skills and data collection; subjective and objective.

What are the 5 stages of the nursing process? ›

These are:
  • Assess.
  • Diagnose.
  • Plan.
  • Implement.
  • Evaluate.

What is the nursing process and why is it used? ›

The nursing process is a systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness. It has five steps; Assessment, Diagnosis, planning, implementation and evaluation [5].

What are the 6 components of the nursing process? ›

The mnemonic ADOPIE is an easy way to remember the ANA Standards and the nursing process. Each letter refers to the six components of the nursing process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.

What are the 5 steps of the nursing process quizlet? ›

The American Nurses Association (ANA) (1973) identified the five steps of the nursing process: (1) assessment, (2) diagnosis, (3) planning (including outcome identification), (4) implementation, and (5) evaluation.

What are the 5 stages of the Adpie nursing process? ›

The acronym ADPIE stands for assessment, diagnosis, planning, implementation, and evaluation. These five sequential steps help ensure a consistent level of care by identifying the patient's needs, planning and implementing care accordingly, and evaluating treatment by observing the patient's response.

What are the stages of nursing in order? ›

What are the different levels of nursing?
  • Certified Nursing Assistant (CNA)
  • Licensed Practical Nurse (LPN)
  • Registered Nurse (RN)
  • Advanced Practice Registered Nurse (APRN)

What is an example of the nursing process? ›

Example: A new patient is admitted to the unit. The nurse obtains the patient's blood pressure, heart rate, respiration rate, temperature, and oxygen saturation. The nurse performs a head-to-toe assessment and gauges the patient's pain level. The nurse documents this information.

What is the most important step in the nursing process? ›

The assessment phase is a critical component of the nursing process. Information gathered in this phase is used to establish a foundation upon which all patient care moving forward is established.

What is known as nursing process? ›

The nursing process consists of five steps: assessment, diagnosis, planning, implementation, and evaluation. The acronym ADPIE is an easy way to remember the components of the nursing process.

What is replacing the nursing process? ›

Clinical judgment is currently replacing the nursing process, originally developed by Ida Jean Orlando in 1961. The NCJMM recognizes six cognitive skills necessary for appropriate clinical judgments: Recognize Cues. Analyze Cues.

What are the 4 elements of nursing? ›

Fawcett has named person, health, environment and nursing as the four main concepts of nursing that need to be comprehensively defined.

What are the basic nursing procedures? ›

Every nurse needs to master basic procedures such as taking vital signs, administering medication, providing wound care, performing physical assessments, inserting and managing intravenous (IV) lines, and conducting patient education.

What are the 5 steps in the nursing process? ›

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 is the first step and involves critical thinking skills and data collection; subjective and objective.

What is the primary purpose of the nursing process? ›

The purpose of the nursing process is to create a standard of care where the nurse develops a nursing diagnosis and care plan based on their assessment of the patient. Each care plan is unique and provides care that is centered around the individual patient.

What are the standard nursing steps? ›

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.

What are the 5 stages of nursing ability? ›

  • Benner's Stages of Clinical Competence. In the acquisition and development of a skill, a nurse passes through five levels of proficiency: novice, advanced beginner, competent, proficient, and expert.
  • Stage 1: Novice. ...
  • Stage 2: Advanced Beginner. ...
  • Stage 3: Competent. ...
  • Stage 4: Proficient. ...
  • Stage 5: The Expert.

What is the rule of 5 in nursing? ›

Most health care professionals, especially nurses, know the “five rights” of medication use: the right patient, the right drug, the right time, the right dose, and the right route—all of which are generally regarded as a standard for safe medication practices.

What are the five priorities of nursing care? ›

  • 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. Assessment. ...
  • Diagnosis. ...
  • Outcomes / Planning. ...
  • Implementation. ...
  • Evaluation.

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