The Nursing Process
Regardless of practice area or specialty, nurses use the same framework of nursing care, called the nursing process. The American Nurses Association describes the nursing process as the crucial core of practice delivering holistic, client-focused nursing care. Originally a five-phase process, the nursing process today consists of six phases: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.
Assessment: Assessment is the systematic collection of subjective (what the client says) and objective (what the nurse sees, hears, smells, and feels) information from the client. During this phase, nurses consider the physical, psychological, sociocultural, and spiritual factors that may affect the client's health situation. Nurses perform initial, comprehensive assessments when they first admit a client to a hospital setting, when they accept a new client into a physician's office or clinic, and when they first visit a home healthcare client. These assessments are quite detailed and require significant time to perform because of the amount of data needed when clients have problems that have yet to be identified. Nurses complete focused assessments on clients whose problem has been identified to note whether that problem has worsened, improved, or resolved. These assessments are shorter in duration and more concise, and they are typically performed on a regular basis. For example, a nurse working in an intensive care unit may assess a client's blood pressure every few minutes. Time-elapsed visits also require nursing assessment. These vary in duration and frequency, depending on the client's health issues. Examples include annual health visits for children or interval assessments for weight reduction. The last but crucial type is emergency assessment for life-threatening situations when nurses must remember their ABCs—airway, breathing, and circulation, especially for clients with heart or lung problems. Nurses must also have emergency psychological skills in order to assess clients who may want to kill themselves or harm others.
Diagnosis: While APNs can make medical diagnoses, most nurses cannot. Nurses diagnose human responses to actual or potential health problems after analyzing and interpreting the data they collect from their assessment. The North American Nursing Diagnosis Association (NANDA) defines nursing diagnosis as "a clinical judgment about individual, family or community responses to actual or potential health problems or life processes, which provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable." Nursing diagnoses guide the selection of interventions that are likely to produce the desired treatment effects and determine nurse-sensitive outcomes. They also provide a means of communicating client care requirements to other nurses.
Outcomes identification: Nurses use assessments and diagnoses to create measurable and achievable short- and long-term goals. The newest addition to the nursing process, outcome identification, provides individualized care, promotes client participation, plans care that is realistic and measurable, and allows for the involvement of support personnel. Nurses use their knowledge and skills to prioritize client outcomes. High priorities include lifethreatening situations like hemorrhaging, events that require immediate attention such as discharge planning, and issues that are extremely important to the client such as pain. Low priorities involve problems that usually resolve with little attention, such as discomfort from minor surgery.
Planning: Planning refers to the development of nursing strategies that can alleviate the client's problems. To meet the standards of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), the plan must be developed by an RN, documented in the client's healthcare record, and reflect the standards of care established by the institution and the profession. Medicare and Medicaid, and some third-party reimbursement plans (e.g., health insurance) require care plans for each client.
Implementation: Nurses implement client care according to the care plan to assure the continuity of care during hospitalization, discharge, and home care. The purpose of this action phase of the nursing process is to provide individualized therapeutic and technical care to help the client achieve an optimal level of health. Nurses may delegate some interventions to other members of the healthcare team; however, RNs maintain the responsibility and accountability for the supervision and evaluation of these personnel.
Evaluation: RNs continuously evaluate both the client's status and the effectiveness of the client's care. They then modify the care plan as needed. During this phase, nurses conduct a thorough, systematic review of the effectiveness of their nursing interventions and a determination of client goal achievement. The nurse appraises goal attainment jointly with the client. While evaluation is a distinct phase, it occurs throughout the nursing process to assure prompt reassessment, rediagnosing, and replanning when needed.