Nursing Process
The nursing process is based on a nursing theory development and it is an essential part of the nursing care plan It consists of basically five steps
Assessment
This is the data collection step. For RNs it also entails analyzing the data
Assessment involves taking vital signs, performing a head to toe assessment, listening to the patient's comments and questions about his health status, observing his reactions and interactions with others. It involves asking per tenant questions about his signs and symptoms, and listening carefully to the answers
Once you have collected the data, the process moves on to analysis of the data to determine the health status, the patient's coping mechanisms or lack thereof, his ability to use these mechanisms and to identify his problems related to his health status
Diagnosis
Nurses only make nursing diagnoses, except in the case of Nurse Practitioners who have been trained and licensed to make medical diagnoses
Once you have identified the patient's problems related to his health status, you formulate a nursing diagnosis for each of them. You will also prioritize the problems in formulating your plan and goals
The RN chooses a nursing diagnosis list which most closely describes the patient's problem related to his health status. This might be a current problem or a potential problem which needs to be addressed. It can even be a problem that relates to his family rather then to him alone such as the family's inability to cope with life style changes necessitated by the patient's illness
Planning
Setting goals to improve the outcomes for the patient are a primary focus of the nursing process. Based on the nursing diagnoses, what are the expectations for this patient? This not about nursing goals. This is about improving the quality of life for your patient. This is about what your patient needs to do to improve his health status or better cope with his illness
Planning also involves making plans to carry out the necessary interventions to achieve those goals. The use of formal care plans or care maps and protocols is highly advised
Implementation
Setting your plans in motion and delegating responsibilities for each step. Communication is essential to the nursing process. All members of the health care team should be informed of the patient's status and nursing diagnosis, the goals and the plans. They are also responsible to report back to the RN all significant findings and to ******** their observations and interventions as well as the patient's response and outcomes
Evaluation
The nursing process is an ongoing event. Evaluation involves not only analyzing the success of the goals and interventions, but examining the need for adjustments and changes as well. Evaluation leads back to Assessment and the whole process begins again. The evaluation incorporates all input from the entire health care team, including the patient
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