Nursing 101 - The Nursing Process
AssessmentThe first step in delivering nursing care is to collect and analyze data of patients in a systematic and dynamic way. In the assessment stage of the nursing process, relevant data is collected including physiological, psychological, economic, lifestyle, socio-cultural, and spiritual data. These data are used to analyze the circumstance of the patient in relation to the ailment. For example, the nurse doesn"t simply sop at describing and assessing the physical causes and symptoms of pain. The nurse also looks at the patient"s response and the surrounding circumstances such as refusal to eat, laziness, lethargy, aggression, anger towards the hospital staff, request for pain medication, and positive or negative relationship with family members.
Diagnosis
The diagnosis is the nurse"s clinical judgment of the client"s actual or potential condition and the care the patient needs and is thus the basis for the nurse"s care plan. It also reflects the problems that the condition might have caused such as poor nutrition, anxiety, withdrawal, and conflict, as well as the potential cause of the complications.
Planning
The nurse will then set out short-term and long-term measurable goals for the patient based on the assessment and diagnosis. Goals can be include nutrition plan, medications, therapy, pain management, and counseling. All the data, from the assessment to the planning stage are written in the nurse"s care plan for the patient so that other nurses and doctors have access to it.
Implementation
Implementation is done according to the nurse"s written care plan and may evolve during cycles of the nursing process. All provided care and changes to implementation is documented in the patient"s record so that there is a continuity of care during the entire hospitalization time of the patient.
Evaluation
During the whole process, the status of the patient is evaluated as well as the effectiveness of the nursing care provided. Along the way, the nursing care plan is modified as required.