Nursing Process

The nursing process, which consists of five sequential processes, serves as a methodical guide to providing client-centered care. Assessment, diagnosis, planning, execution, and evaluation are the steps involved.

Assessment

The first phase is assessment, which entails the use of critical thinking abilities as well as data collecting, both subjective and objective. Subjective data consists of vocal utterances made by the patient or by a caregiver on their behalf. Measureable and tangible data such as vital signs, intake and output, height and weight are all examples of objective data.

Data may be collected directly from the patient or indirectly through main caregivers who may or may not be related to the patient directly. Friends can assist in the data collecting process. Electronic health records may be used to input data and aid in the evaluation process.

Critical thinking abilities are required for evaluation, resulting in the necessity for concept-based curricular modifications.

Diagnosis

The development of a nursing diagnosis by the use of clinical judgment is beneficial in the planning and administration of patient care.

North American Nursing Diagnosis Association (NANDA) supplies nurses with a comprehensive list of nursing diagnoses that is kept up to date. According to the National Association of Nurse Diagnosis and Treatment (NANDA), a nursing diagnosis is described as a clinical judgment concerning reactions to existing or anticipated health concerns on the part of the patient, family, or community.

A nursing diagnosis incorporates Maslow’s Hierarchy of Needs and aids in the prioritization and planning of patient-centered outcomes-based interventions. Abraham Maslow devised a hierarchy of needs in 1943 that is based on the basic wants that are inherent in all persons. Higher-level physiological needs/goals, such as self-esteem and self-actualization, cannot be reached until the basic physiological needs/goals are addressed. The execution of nursing care and nursing interventions is based on the demands of the patient’s physiological and safety requirements. As a result, they are at the bottom of Maslow’s pyramid, providing the groundwork for both physical and emotional well-being. [4] [5]

Maslow’s Hierarchy of Needs is a theory that describes how people need to be satisfied in various ways.

Nutrition (water and food), elimination (toilet), airway (suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABC’s), sleep, sex, shelter, and exercise are all basic physiological requirements.
Infection control and prevention (side rails, call lights, hand hygiene, isolation, suicide prevention measures, fall prevention measures, car seats, helmets, seat belts), creating an environment of trust and safety (therapeutic relationship), and patient education are all important aspects of patient safety and security (modifiable risk factors for stroke, heart disease).
Connections of Love and Belonging: Develop supportive relationships, utilize measures to prevent social isolation (bullying), employ active listening skills, therapeutic dialogue, and engage in sexual intimacy.
Acceptance in the community, the workplace, personal success, a sense of control or empowerment, acceptance of one’s physical appearance or bodily habitus are all indicators of one’s self-esteem.
Self-Actualization includes the following elements: an empowering environment, spiritual growth, the capacity to appreciate the points of view of others, and realizing one’s full potential in life.
Planning

The planning stage is the step in which goals and results are developed that have a direct influence on patient care in accordance with EDP principles. These patient-specific objectives, as well as the achievement of these objectives, contribute to the achievement of a favorable outcome. It is critical to have nursing care plans in place throughout this stage of goal planning. Care plans lay out a course of action for providing individualized care that is tailored to the specific requirements of each client. The overall status of the patient as well as any comorbid conditions are taken into consideration while developing a treatment plan. Treatment plans improve communication, documentation, payment, and the continuity of care along the healthcare continuum, according to the Institute of Medicine.

The following should be the objectives:

Action or goal that is specific, measurably meaningful, and attainable

-Results-Oriented Realistic or Result-Oriented

Implementation that is -Oriented and Timely or Time-Oriented Implementation

Implementation is the stage that includes taking action or doing something, as well as the actual carrying out of nursing interventions that are stated in the plan of care. Nursing interventions such as the use of a heart monitor or oxygen, direct or indirect care, prescription administration, standard treatment procedures, and EDP standards are required during this period.

Evaluation

The importance of this final phase in the nursing process cannot be overstated in terms of ensuring a happy patient outcome. A healthcare professional must analyze or evaluate every situation in which he or she intervenes or provides treatment, in order to guarantee that the desired outcome has been achieved. Depending on the general status of the patient, reassessment may be required on a regular basis. The plan of care may need to be revised in light of fresh assessment findings.

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