Improving Practice: Understanding the Steps within the Nursing Process

Some of you might be recent to nursing school, while others are more experienced in your profession. Regardless of experience, using the nursing process is vital to providing patient-centered care. These steps result in improved patient satisfaction and personalized care.

Do you remember the five steps of the nursing process? They are and .

Let’s review these steps. Imagine that the patient is a first-time breastfeeding mother and her baby is barely eight hours old. Using the nursing process, we are going to assess, diagnose, plan, implement, and evaluate from this patient’s perspective.

Rating

This first step within the nursing process involves collecting physiological, psychological, social, spiritual, economic, and lifestyle data. It also requires critical ponderingsharp observational skills, intuitionand lively listening to find out what information is most significant.

Information gathered in the course of the assessment may come directly from the patient or from members of the family and supporters. It may include details which are each objective and subjective:

• : This kind of information is clear and measurable. In our previous scenario, for instance the patient reports that breastfeeding is incredibly painful and her nipples are sore. You observe her breastfeeding and see that the infant has a shallow latch and her nipples are red and cracked. Details similar to the condition of the patient’s nipples and remark of the infant’s sucking could be objective data to incorporate within the notes.
• This information may vary, however it is concerning the perception or feelings of the patient. In the case of our first-time mother, her perception of how breastfeeding goes, whether there may be pain, and the infant’s satisfaction with breastfeeding are subjective. In addition, verbal statements by the patient, family, or family members may be considered subjective. For example, a mother’s statements similar to “I didn’t know it would be so difficult” with a tearful response or her spouse’s statements similar to “I just want our baby to eat and my wife to rest” are considered subjective because they consult with the emotions and perceptions of each the patient and her family. It is vital to incorporate this within the documentation because it will possibly provide a more comprehensive insight into what the patient is experiencing.

Diagnosis

After a radical assessment, it’s time to make a nursing diagnosis using clinical judgment. North American Nursing Diagnostic Association (NANDA-I) maintains a listing of nursing diagnoses. This is your response to real or potential health problems, based on Maslow’s pyramid of needsand helps plan and prioritize care.

In our original example, the next nursing diagnosis was used based in your assessment:

• Ineffective breastfeeding
• Related to maternal breast pain, insufficient knowledge and insufficient family support
• What is evidenced by the lack to properly latch on to the breast, sore nipples, the infant crying after feeding and the statements of the patient and partner

In the diagnosis stage, there are three components: the issue, the etiology (cause), and the defining characteristics or risk aspects. Each diagnosis is placed in a category. The NANDA-I identifies 4 categories: problem-focused diagnosis, risk diagnosis, health promotion diagnosis, and syndrome. In our example, we use a problem-focused diagnosis based on the issue, etiology, and characteristics identified in our first-time assessment of the mother.

Diagnosis drives nursing interventions and the care plan. Correct nursing diagnoses will help increase patient safety, improve quality of care, and even increase insurance reimbursement.

Result/Planning

In the outcomes/planning phase, you may establish measurable and achievable goals after completing the primary two steps. These goals (each short-term and long-term) are outlined within the patient’s care plan to assist ensure continuity of care and improve communication.

For a breastfeeding mother, the next examples of expected results may very well be considered:

• On the primary day, the patient will have the option to appropriately display methods to put the infant to the breast and the feeding position.
• On the second day, the patient will begin to verbally report reduced pain during breastfeeding.
• On the day of discharge, the patient will verbalize her satisfaction with breastfeeding.

Remember, your goals ought to be as specific as possible. The expected results should be measurable and achievable. They must even be realistic and timely.

The final result and planning phase of the nursing process requires you to prioritize your patient’s needs. It involves decision-making and good communication skills. Your care plan will determine the planned interventions.

Implementation

You are finally ready for the implementation phase of the nursing process. Now you may put careful assessment, diagnosis, and planning into motion.

For the patient in our example, you might implement the next interventions:

• Refer the patient to a stationary lactation consultant.
• Assist the mother in numerous breastfeeding positions.
• Encourage direct contact.
• Provide emotional support.
• Involve the patient’s partner.

Implementation includes using a care plan that enables for continuity between nursing shifts. Verbal communication skills are essential to communicating your goals for the patient and what interventions you might be using.

Interpersonal skills are also key at this stage. Helping and inspiring the patient without being pushy or intrusive will increase the likelihood of successful implementation.

Rating

The steps within the nursing process are accomplished only after the effectiveness of care has been assessed. During this step, you establish whether the patient has achieved the specified outcomes. However, if the specified outcomes haven’t been achieved, your care plan may be modified as needed.

Assessment is ongoing. It may result in reassessment and transforming of steps. This requires diligence and demanding pondering skills.

In the case of our breastfeeding patient, you assess her progress at the tip of your shift and determine that she will now show you three breastfeeding positions. The lactation consultant has met along with her and worked on improving her sucking. However, her nipples are still sore. Based in your assessment, you add recent interventions to your plan and request a prescription for lanolin ointment for her nipples. You also teach her methods to air dry her nipples and supply her with cooling gel pads. Finally, you document these changes in her care plan.

Ready to enhance your nursing practice? Using the steps of the nursing process will just do that. Remember, these steps are used over and all over again within the delivery of care. Once you reach the assessment stage, return to rating to gather current data and modify the care plan.