Chapter 3 The Nursing Process

Photo of author

By nclexnursing

The nursing process is a method of addressing a person’s health care and nursing needs through purposeful problem-solving. Although numerous writers have expressed the steps of the nursing process in different ways, the common components identified are assessment, diagnosis, planning, implementation, and evaluation. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation are all included in the ANA’s Standards of Clinical Nursing Practice (1998), which establish the sequence of steps in the following order: assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The nursing process will be based on the standard five steps for the purposes of this text, with two components in the diagnosis step: nursing diagnoses and collaborative problems. The desired objectives are typically obvious once the diagnoses or problems have been determined. The following are the traditional steps:

Assessment

Assessment (Data analysis is provided as part of the evaluation.) Analysis might be identified as a separate step of the nursing process by those who want to emphasize its importance.

  1. Gather information about your medical history.
  2. Conduct a physical examination.
  3. Talk with the patient’s relatives or close friends.
  4. Examine your health records.
  5. Organize, evaluate, synthesize, and summarize the information gathered.

Diagnosis

The following two types of patient issues should be identified:

a. Nursing diagnoses: Actual or probable health issues that can be treated with autonomous nursing treatments.

b. Collaborative problems. Nurses monitor certain physiologic complications to detect onset or changes in status. Nurses address collaborative difficulties by implementing physician- and nurse-prescribed interventions to reduce the severity of the events.” (Page 7 of Carpenito’s 1999 book).

  1. Determine the patient’s nursing issues.
  2. Define the nursing challenges’ distinguishing characteristics.
  3. Determine the cause of the nursing issues.
  4. State nursing diagnoses in a concise and exact manner.

Collaboration Issues

  1. Identify prospective issues or obstacles that will necessitate collaborative solutions.
  2. Identify members of the health care team with whom you must collaborate.

Planning

Goals and outcomes are developed, as well as a treatment plan to support the patient in resolving the diagnostic problems and achieving the defined goals and results.

  1. Give nursing diagnoses first attention.
  2. Define the objectives.
    a. Create short-, medium-, and long-term objectives.
    b. State the objectives in words that are both practical and measurable.
  3. Identify nursing interventions that will help you achieve your goals.
  4. Determine what you want to happen.
    a. Make sure the outcomes are attainable and quantifiable.
    a. Determine critical times for achieving objectives.
  5. Create a written nursing care plan.
    a. Include nursing diagnoses, goals, nursing interventions, expected outcomes, and important timeframes in your document.
    b. Ensure that all entries are written clearly, simply, and in a logical order.
    c. Keep the plan up to date and adaptable to the patient’s changing difficulties and requirements.
  6. Include the patient, family or significant others, nursing team members, and other members of the health care team in all phases of the planning process.

Implementation

Nursing interventions help to make the care plan a reality.

  1. Put your nursing care strategy into action.
  2. Coordinate the activities of the patient, his or her family or significant others, the nursing team, and other members of the health care team.
  3. Take notes on the patient’s reactions to the nursing interventions.

Evaluation

The extent to which the patient’s responses to the nursing interventions and the outcomes have been attained.

  1. Gather information.
  2. Make a comparison between the patient’s actual and projected outcomes. Determine whether or not the desired objectives were attained.
  3. Involve the patient, his or her family or significant others, nursing staff, and other members of the health-care team in the evaluation.
  4. Determine whether any changes to nursing diagnoses, collaborative problems, goals, nursing actions, or expected outcomes are required.
  5. Complete the nursing process in its entirety, including assessment, diagnosis, planning, execution, and evaluation.

This is a list of nursing diagnoses that have been approved by NANDA for clinical usage and assessment.

Exchanging

  • Imbalanced nutrition: More than body requirements
  • Imbalanced nutrition: Less than body requirements
  • Risk for imbalanced nutrition: More than body requirements
  • Risk for infection
  • Risk for imbalanced body temperature
  • Hypothermia
  • Hyperthermia
  • Ineffective thermoregulation
  • Autonomic dysreflexia
  • Risk for autonomic dysreflexia
  • Constipation
  • Perceived constipation
  • Diarrhea
  • Bowel incontinence
  • Risk for constipation
  • Impaired urinary elimination
  • Stress urinary incontinence
  • Reflex urinary incontinence
  • Urge urinary incontinence
  • Functional urinary incontinence
  • Total urinary incontinence
  • Risk for urge urinary incontinence
  • Urinary retention
  • Ineffective tissue perfusion (specify type: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral)
  • Risk for imbalanced fluid volume
  • Excess fluid volume
  • Deficient fluid volume
  • Risk for deficient fluid volume
  • Decreased cardiac output
  • Impaired gas exchange
  • Ineffective airway clearance
  • Ineffective breathing pattern
  • Impaired spontaneous vententilation
  • Dysfunctional ventilatory weaning response
  • Risk for injury
  • Risk for falls*
  • Risk for suffocation
  • Risk for poisoning
  • Risk for trauma
  • Risk for aspiration
  • Risk for disuse syndrome
  • Latex allergy response
  • Risk for latex allergy response
  • Ineffective protection
  • Impaired tissue integrity
  • Impaired oral mucous membrane
  • Impaired skin integrity
  • Risk for impaired skin integrity
  • Impaired dentition
  • Decreased intracranial adaptive capacity
  • Disturbed energy field

Communicating

  • Impaired verbal communication

Relating

  • Impaired social interaction
  • Social isolation
  • Risk for loneliness
  • Ineffective role performance
  • Impaired parenting
  • Risk for impaired parenting
  • Risk for impaired parent/infant/child attachment
  • Sexual dysfunction
  • Interrupted family processes
  • Caregiver role strain
  • Risk for caregiver role strain
  • Dysfunctional family processes: Alcoholism
  • Parental role conflict
  • Ineffective sexuality patterns

Valuing

  • Spiritual distress
  • Risk for spiritual distress
  • Readiness for enhanced spiritual well-being

Choosing

  • Ineffective coping
  • Impaired adjustment
  • Defensive coping
  • Ineffective denial
  • Disabled family coping
  • Compromised family coping
  • Readiness for an enhanced family coping
  • Readiness for enhanced community coping
  • Ineffective community coping
  • Ineffective therapeutic regimen management
  • Noncompliance (specify)
  • Ineffective family therapeutic regimen management
  • Ineffective community therapeutic regimen management
  • Effective therapeutic regimen management
  • Decisional conflict (specify)
  • Health-seeking behaviors (specify

Moving

  • Impaired physical mobility
  • Risk for peripheral neurovascular dysfunction
  • Risk for perioperative-positioning injury
  • Impaired walking
  • Impaired wheelchair mobility
  • Impaired transferability
  • Impaired bed mobility
  • Activity intolerance
  • Fatigue
  • Risk for activity intolerance
  • Disturbed sleep pattern
  • Sleep deprivation
  • Deficient diversional activity
  • Impaired home maintenance
  • Ineffective health maintenance
  • Delayed surgical recovery
  • Adult failure to thrive
  • Feeding self-care deficit
  • Impaired swallowing
  • Ineffective breastfeeding
  • Interrupted breastfeeding
  • Effective breastfeeding
  • Ineffective infant feeding pattern
  • Bathing/hygiene self-care deficit
  • Dressing/grooming self-care deficit
  • Toileting self-care deficit
  • Delayed growth and development
  • Risk for delayed development
  • Risk for disproportionate growth
  • Relocation stress syndrome
  • Risk for relocation stress syndrome*
  • Risk for disorganized infant behavior
  • Disorganized infant behavior
  • Readiness for enhanced organized infant behavior
  • Wandering*

Perceiving

  • Disturbed body image
  • Chronic low self-esteem
  • Situational low self-esteem
  • Risk for situational low self-esteem*
  • Disturbed personal identity
  • Disturbed sensory perception (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)
  • Unilateral neglect
  • Hopelessness
  • Powerlessness
  • Risk for powerlessness

Knowing

  • Deficient knowledge (specify)
  • Impaired environmental interpretation syndrome
  • Acute confusion
  • Chronic confusion
  • Disturbed thought processes
  • Impaired memory

Feeling

  • Acute pain
  • Chronic pain
  • Nausea
  • Dysfunctional grieving
  • Anticipatory grieving
  • Chronic sorrow
  • Risk for other-directed violence
  • Self-mutilation*
  • Risk for self-mutilation
  • Risk for self-directed violence
  • Risk for suicide Post-trauma syndrome
  • Rape-trauma syndrome
  • Rape-trauma syndrome: Compound reaction
  • Rape-trauma syndrome: Silent reaction
  • Risk for post-trauma syndrome
  • Anxiety
  • Death anxiety
  • Fear

Establishing expected outcomes

Establishing goals

Determining Nursing Actions

The nurse, with input from the patient and significant others, identifies tailored treatments based on the patient’s circumstances and preferences that will address each outcome when planning suitable nursing activities to achieve the intended goals and results. Interventions should specify the activities that will be carried out as well as who will carry them out. Interdisciplinary activities are determined in consultation with other health care providers as needed.