Nursing process
Encyclopedia
The nursing process is a modified scientific method
. Nursing practise was first described as a four stage nursing process by Ida Jean Orlando in 1958,. It should not be confused with nursing theories
or Health informatics
. The diagnosis phase was added later.
The nursing process uses clinical judgement to strike a balance of Epistomology between personal interpretation and research evidence in which critical thinking
may play a part to categorize the clients issue and course of action. Nursing offers diverse patterns of knowing. Nursing knowledge has embraced pluralism since the 1970's.
Some authors refer to a Mind map
or Abductive reasoning as a potential alternative strategy for organizing care. Intuition
plays a part for experienced nurses.
According to some theorists, this five stage description of the nursing process is outdated and misrepresents nursing as linear and atomic.
of the needs of the individual/family/community, regardless of the reason for the encounter. The nurse collects subjective
data
and objective
data
using a nursing framework, such as Marjory Gordon's functional health patterns
.
How to collect data
represent the nurse's clinical judgment about actual or potential health problems/life process occurring with the individual, family, group or community. The accuracy of the nursing diagnosis is validated when a nurse is able to clearly identify and link to the defining characteristics, related factors and/or risk factors found within the patient’s assessment. Multiple nursing diagnoses may be made for one client.
to allow for the use of standardized language which improves consistency of terminology, definition and outcome measures. The interventions used in the Nursing Interventions Classification
again allow for the use of standardized language which improves consistency of terminology, definition and ability to identify nursing activities, which can also be linked to nursing workload and staffing indices. The result of this phase is a nursing care plan
.
, performing the determined interventions that were selected to help meet the goals/outcomes that were established. Delegated tasks and the monitoring of them is included here as well.
The entire process is recorded or documented in order to inform all members of the health care team.
Scientific method
Scientific method refers to a body of techniques for investigating phenomena, acquiring new knowledge, or correcting and integrating previous knowledge. To be termed scientific, a method of inquiry must be based on gathering empirical and measurable evidence subject to specific principles of...
. Nursing practise was first described as a four stage nursing process by Ida Jean Orlando in 1958,. It should not be confused with nursing theories
Nursing theory
Nursing theory is the term given to the body of knowledge that is used to define or explain various aspects of the profession of nursing.-Grand nursing theories:...
or Health informatics
Health informatics
.Health informatics is a discipline at the intersection of information science, computer science, and health care...
. The diagnosis phase was added later.
The nursing process uses clinical judgement to strike a balance of Epistomology between personal interpretation and research evidence in which critical thinking
Critical thinking
Critical thinking is the process or method of thinking that questions assumptions. It is a way of deciding whether a claim is true, false, or sometimes true and sometimes false, or partly true and partly false. The origins of critical thinking can be traced in Western thought to the Socratic...
may play a part to categorize the clients issue and course of action. Nursing offers diverse patterns of knowing. Nursing knowledge has embraced pluralism since the 1970's.
Some authors refer to a Mind map
Mind map
A mind map is a diagram used to represent words, ideas, tasks, or other items linked to and arranged around a central key word or idea. Especially in British English, the terms spidergram and spidergraph are more common, but they can cause confusion with the term spider diagram used in mathematics...
or Abductive reasoning as a potential alternative strategy for organizing care. Intuition
Intuition (knowledge)
Intuition is the ability to acquire knowledge without inference or the use of reason. "The word 'intuition' comes from the Latin word 'intueri', which is often roughly translated as meaning 'to look inside'’ or 'to contemplate'." Intuition provides us with beliefs that we cannot necessarily justify...
plays a part for experienced nurses.
Phases of the nursing process
The nursing process is goal-oriented method of caring that provides a framework to nursing care. It involves five major steps:- A - AssessNursing assessmentNursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status.-Stage one of the nursing process:...
(what data is collected?) - D - DiagnoseNursing diagnosisA nursing diagnosis may be part of the nursing process and is a clinical judgement about individual, family, or community experiences/responses to actual or potential health problems/life processes...
(what is the problem?) - O - Outcome Identification - (Was originally a part of the Planning phase, but has recently been added as a new step in the complete process).
- P - PlanNursing care planA nursing care plan outlines the nursing care to be provided to an individual/family/community. It is a set of actions the nurse will implement to resolve/support nursing diagnoses identified by nursing assessment. The creation of the plan is an intermediate stage of the nursing process...
(how to manage the problem) - I - Implement (putting plan into action)
- E - Evaluate (did the plan work?)
According to some theorists, this five stage description of the nursing process is outdated and misrepresents nursing as linear and atomic.
Assessing phase
The nurse completes an holistic nursing assessmentNursing assessment
Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status.-Stage one of the nursing process:...
of the needs of the individual/family/community, regardless of the reason for the encounter. The nurse collects subjective
Subjectivity
Subjectivity refers to the subject and his or her perspective, feelings, beliefs, and desires. In philosophy, the term is usually contrasted with objectivity.-Qualia:...
data
Data
The term data refers to qualitative or quantitative attributes of a variable or set of variables. Data are typically the results of measurements and can be the basis of graphs, images, or observations of a set of variables. Data are often viewed as the lowest level of abstraction from which...
and objective
Objectivity (science)
Objectivity in science is a value that informs how science is practiced and how scientific truths are created. It is the idea that scientists, in attempting to uncover truths about the natural world, must aspire to eliminate personal biases, a priori commitments, emotional involvement, etc...
data
Data
The term data refers to qualitative or quantitative attributes of a variable or set of variables. Data are typically the results of measurements and can be the basis of graphs, images, or observations of a set of variables. Data are often viewed as the lowest level of abstraction from which...
using a nursing framework, such as Marjory Gordon's functional health patterns
Gordon's functional health patterns
Gordon's functional health patterns is a method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive nursing assessment of the patient.-Health Perception and Management:...
.
Models for data collection
Nursing assessments provide the starting point for determining nursing diagnoses. It is vital that a recognized nursing assessment framework is used in practice to identify the patient’s* problems, risks and outcomes for enhancing health. The use of an evidence-based nursing framework such as Gordon’s Functional Health Pattern Assessment should guide assessments that support nurses in determination of NANDA-I nursing diagnoses. For accurate determination of nursing diagnoses, a useful, evidence-based assessment framework is best practice.How to collect data
- Client Interview
- Physical Examination
- Obtaining a health history (including dietary data)
- Family history/report
- Diagnostic Data
- Observation
Diagnosing phase
Nursing diagnosesNursing diagnosis
A nursing diagnosis may be part of the nursing process and is a clinical judgement about individual, family, or community experiences/responses to actual or potential health problems/life processes...
represent the nurse's clinical judgment about actual or potential health problems/life process occurring with the individual, family, group or community. The accuracy of the nursing diagnosis is validated when a nurse is able to clearly identify and link to the defining characteristics, related factors and/or risk factors found within the patient’s assessment. Multiple nursing diagnoses may be made for one client.
Planning phase
In agreement with the client, the nurse addresses each of the problems identified in the diagnosing phase. When there are multiple nursing diagnoses to be addressed, the nurse prioritizes which diagnoses will receive the most attention first according to their severity and potential for causing more serious harm. For each problem a measurable goal/outcome is set. For each goal/outcome, the nurse selects nursing interventions that will help achieve the goal/outcome. A common method of formulating the expected outcomes is to use the evidence-based Nursing Outcomes ClassificationNursing Outcomes Classification
The Nursing Outcomes Classification is a classification system which describes patient outcomes sensitive to nursing intervention. The NOC is a system to evaluate the effects of nursing care as a part of the nursing process...
to allow for the use of standardized language which improves consistency of terminology, definition and outcome measures. The interventions used in the Nursing Interventions Classification
Nursing Interventions Classification
The Nursing Interventions Classification is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associate with the creation of a nursing care plan. The NIC consists of a standardized list which contains 433...
again allow for the use of standardized language which improves consistency of terminology, definition and ability to identify nursing activities, which can also be linked to nursing workload and staffing indices. The result of this phase is a nursing care plan
Nursing care plan
A nursing care plan outlines the nursing care to be provided to an individual/family/community. It is a set of actions the nurse will implement to resolve/support nursing diagnoses identified by nursing assessment. The creation of the plan is an intermediate stage of the nursing process...
.
Implementing phase
The nurse implements the nursing care planNursing care plan
A nursing care plan outlines the nursing care to be provided to an individual/family/community. It is a set of actions the nurse will implement to resolve/support nursing diagnoses identified by nursing assessment. The creation of the plan is an intermediate stage of the nursing process...
, performing the determined interventions that were selected to help meet the goals/outcomes that were established. Delegated tasks and the monitoring of them is included here as well.
Evaluating phase
The nurse evaluates the progress toward the goals/outcomes identified in the previous phases. If progress towards the goal is slow, or if regression has occurred, the nurse must change the plan of care accordingly. Conversely, if the goal has been achieved then the care can cease. New problems may be identified at this stage, and thus the process will start all over again.Characteristics of the nursing process
The nursing process is a cyclical and ongoing process that can end at any stage if the problem is solved. The nursing process exists for every problem that the individual/family/community has. The nursing process not only focuses on ways to improve physical needs, but also on social and emotional needs as well.
- Cyclic and dynamic
- Goal directed and client centered
- Interpersonal and collaborative
- Universally applicable
- Systematic
The entire process is recorded or documented in order to inform all members of the health care team.
See also
- Clinical Care Classification SystemClinical Care Classification SystemClinical Care Classification SystemThe Clinical Care Classification System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice...
- NursingNursingNursing is a healthcare profession focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life from conception to death....
- Nursing theoryNursing theoryNursing theory is the term given to the body of knowledge that is used to define or explain various aspects of the profession of nursing.-Grand nursing theories:...
- Nursing diagnosisNursing diagnosisA nursing diagnosis may be part of the nursing process and is a clinical judgement about individual, family, or community experiences/responses to actual or potential health problems/life processes...
- NANDANANDANANDA International is a professional organization of nurses standardized nursing terminology that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnoses...