Nurses cannot just rely on their benevolent spirits when providing care to patients. Rather, they need a comprehensive understanding of the processes and procedures that are proven to foster patient care and recovery.
The nursing process is a systematic, five-step, patient-focused process that facilitates nurses in thinking and planning comprehensively about patient care. The process calls heavily upon the nurses’ capacity for scientific reasoning and critical thinking in ensuring that the patients are given the best care.
Critical thinking is a skill that develops overtime with repetitive use of one’s mental faculties. The nurses are first introduced to the nursing process early in their education and later they get to apply the steps in real-life situations with patients in hospitals.
A nurse must be able to use her clinical judgment to set up a plan for the entire shift. The nursing process is a facilitating tool that allows nurses to think outside of the box, while making sure that they are sticking to the basics.
By using the process, nurses can collect information, focus on the patient problems, and set out clear health objectives. Understanding the basics of the nursing process will be the initial step of your nursing career.
Although considered rudimentary, the nursing process is still taught in advanced degrees like the MSN FNP degree and across various nursing specializations. The more knowledge and experience you gain in your nursing profession or specialization, the better you will get at applying the nursing process to almost any and every situation.
The five-step nursing process includes:
ADPIE is the acronym used to signify the five components that make up the process. Nursing professionals are required to know how to apply the nursing process step by step in professional settings.
Assessment is the first phase in the nursing process, and it involves collecting, arranging, verifying, and documenting patient health status. A registered nurse uses this first step to begin delivering nursing care.
Assessment may not only include the patient’s physiological information, but also his sociocultural, psychological, economic, emotional state, and lifestyle factors.
The data is collected in various ways. For example, when nurses first assess the patient at the hospital, they not only inspect them physically, but also listen to the patient responses of loss of appetite, registering of intensity of pain, anger issues, inability to move or get out of bed, or requests for painkillers.
Nurses are then expected to take a holistic view of the entire assessment based both on their own physical inspections and the patient’s account of the condition.
The nurses can obtain data from primary, secondary, and tertiary sources. The patient is the primary source of data, whereas attendants, family members, laboratory reports, and other health professionals all fall under the category of secondary source of data.
Moreover, the data which is obtained from a source outside the patient’s frame of reference, such as surveys and textbooks, etc. are considered tertiary sources.
The assessment phase calls upon the nurses’ critical thinking skills to identify patient problems as well as executing interventions to improve outcomes.
During the second step of the nursing process, the nurse will analyze the data collected and diagnose the patient’s condition.
The diagnosis phase involves a nurse making a nursing judgment about actual or potential health issues with a client. Nurses utilize their clinical judgment to formulate a diagnosis that helps them in the planning and execution of patient care in the following steps.
This phase not only includes an identification of a medical problem, such as insomnia, but also determines the risks and strengths, such as whether or not the client is at risk of developing any further complications due to the intensity or the progression of the disease.
The diagnosis of a patient’s health also takes into account whether the patient is ready for health improvement. The diagnosis phase is the most critical step in the nursing process as it is used to define the course of patient treatment.
Once the diagnosis is completed, planning—the third step of the nursing process—can begin. When the patient, the nurse and the supervising medical staff all agree on the diagnosis, the nurse will then develop a plan of action that considers both short-term and long-term goals.
If the patient has had multiple diagnoses, the senior nurse will review each assessment and prioritize treatments for conditions having higher risks and harsher symptoms. In this stage, measurable goals are set against each condition.
The planning phase includes the formulation of goals and outcomes that would impact the patient’s health directly. Care plans are vital to the nursing process. These plans provide for personalized and tailored care solutions, designed to address the specific needs of a patient.
The implementation phase is when the treatment plan is finally put into action. It involves carrying out all the nursing interventions decided in the care plan.
The care plan is unique for each patient and focused on attainable goals and outcomes. Actions that may be involved in a nursing care plan include performing essential medical tasks, monitoring patients for improvement, educating patients about health management, and contacting and informing the patient for follow up.
The implementation phase requires the patient to be actively involved, as the patient’s involvement is essential for a full follow through on the plan. As a nurse, you will be responsible to monitor the execution of the care plan to ensure continuity.
The evaluation phase is the last, but most essential, step in ADPIE. It basically addresses the question, “Did the plan work?”
We come to know what works and what does not by evaluating what has been done. Once the implementation step has been completed, the nurse, as well as the medical staff, should evaluate the steps taken and identify whether the treatment worked as expected, to ensure the positive result has been met.
The patient outcomes usually fall under any of these three conditions:
- The condition of the patient is improved
- The condition of the patient is stabilized
- The condition of the patient has worsened
In case the patient’s condition showed no improvement, or if the goals and expected outcomes were not met, the nursing process restarts from the beginning, as there could have been an error committed in any of the five stages.
Nurses use the five-step nursing process to systematically provide patients with the care they need. The elements of the process are: assessment, diagnosis, planning, implementation, and evaluation. The process helps nurses stick to the basics of providing health care, meaning that it minimizes room for error.