Understanding and using the nursing process steps is essential for individualized patient-centered care. The five key steps guide nursing care and promote better communication among healthcare team members.
Some of you are fresh out of nursing school, while others are more seasoned in your careers. Regardless of your experience, applying the nursing process is vital to providing patient-centered care. These steps lead to improved patient satisfaction and individualized care.
Do you remember the five nursing process steps? They are assessment, diagnosis, outcome/planning, implementation, and evaluation.
Let's review these steps. Imagine the patient is a first-time mother who is breastfeeding, and her baby is just eight hours old. Using the nursing process, we will assess, diagnose, plan, implement, and evaluate through the lens of this patient.
Assessment
This first step in the nursing process involves collecting physiological, psychological, social, spiritual, economic, and lifestyle data. It also requires critical thinking, astute observational skills, intuition, and active listening to determine which information is the most relevant.
Information collected during the assessment can come directly from the patient or from family members and support people. They can also include details that are both objective and subjective:
- Objective: This type of information is evident and measurable. In our previous scenario, let's say the patient reports that breastfeeding is extremely painful, and nipples are sore. You observe her while she breastfeeds, noting that the baby has a shallow latch, and her nipples are red and cracked. Details like the condition of the patient's nipples and observation of the baby's latch would be objective data to include in your notes.
- Subjective: This information can vary, but it involves a patient's perception or feelings. With our first-time mother, her perception of how breastfeeding is going, whether there is pain, and the baby's satisfaction with breastfeeding are subjective. In addition, verbal statements from the patient, family, or loved ones can be considered subjective as well. For instance, statements from the mother like, "I didn't know this would be so hard," with a tearful response or statements from her spouse such as, "I just want our baby to eat, and my wife to be able to rest," are considered subjective because they relate to feelings and perceptions from both the patient and her family. This is important to include in your documentation, as it can provide more comprehensive insight into what the patient is experiencing.
Diagnosis
After a thorough assessment, it's now time to make nursing diagnoses using clinical judgment. The North American Nursing Diagnosis Association International (NANDA-I) maintains a list of nursing diagnoses. This is your response to actual or potential health problems, is based on Maslow's Hierarchy of Needs, and helps you to plan and prioritize care.
In our original example, the following nursing diagnosis applies based on your assessment:
- Ineffective breastfeeding
- Related to maternal breast pain, inadequate knowledge, and insufficient family support
- As evidenced by an inability to latch on to the breast correctly, sore nipples, infant crying after feeding and patient, and partner statements
At the diagnosis stage, there are three components: the problem, the etiology (cause), and the defining characteristics or risk factors. Each diagnosis is placed into a category. The NANDA-I identifies four categories as problem-focused diagnosis, risk diagnosis, health promotion diagnosis, and syndrome. In our example, we use the problem-focused diagnosis based on the problem, etiology, and characteristics determined in our assessment of the first-time mother.
The diagnosis drives the nursing interventions and care plan. Proper nursing diagnoses can help increase patient safety, improve the quality of care, and even increase reimbursement from insurance companies.
Outcome/planning
At the outcome/planning stage, you can set measurable and achievable goals after following the first two steps. These goals (both short and long term) are charted in your patient's care plan to help provide continuity of care and improve communication.
For the breastfeeding mother, the following examples could be set as expected outcomes:
- On day one, the patient will correctly demonstrate proper breastfeeding latch and positioning.
- By day two, the patient will verbalize decreased pain with breastfeeding.
- By the day of discharge, the patient will verbalize satisfaction with breastfeeding.
Keep in mind that your goals should be as specific as possible. Expected outcomes must be measurable and attainable. They also need to be realistic and timely.
The outcome and planning step of the nursing process requires you to prioritize your patient's needs. It involves decision-making and good communication skills. Your care plan will outline your planned interventions.
Implementation
You're finally ready for the nurse process step of implementation. Careful assessment, diagnosis, and planning can now be put into action.
For the patient in our example, you can implement the following interventions:
- Refer the patient to an inpatient lactation consultant.
- Assist the mother in multiple breastfeeding positions.
- Encourage skin-to-skin contact.
- Provide emotional support.
- Involve the patient's partner.
Implementation involves using the care plan, which allows for continuity across nursing shifts. Verbal communication skills are essential in relaying your goals for your patient and what interventions you use.
Interpersonal skills are also vital at this phase. Assisting and encouraging your patient without being pushy or intrusive will increase the likelihood of successful implementation.
Evaluation
The nursing process steps are only complete once you evaluate the effectiveness of your care. During this step, you determine if the patient has achieved the desired outcomes. However, if the desired outcomes have not been achieved, your care plan can then be modified as needed.
Evaluation occurs on an ongoing basis. It can lead to reassessment and working through the steps again. This requires diligence and critical-thinking skills.
For our breastfeeding patient, you evaluate progress at the end of your shift and determine that she can now show you three positions to nurse her baby. The lactation consultant has met with her and worked on improving the baby's latch. She still has sore nipples, however. Based on your evaluation, you add new interventions to your plan and request a prescription for Lanolin ointment for her nipples. You also teach her to air dry her nipples and provide her with cooling gel pads. Finally, you document these changes in her care plan.
Ready to enhance your nursing practice? Using the nursing process steps will do just that. Remember that these steps are used repeatedly in providing care. Once you reach the evaluation step, return to assessment to collect updated data and modify your care plan.
Learn more about enhancing your nursing practice or other nursing skills in Nurse.com's catalog of CE courses.
