The Nursing Process

The nursing process is something often discussed in nursing theory. Most nurses use the nursing process without realizing it is a part of their careers. That is, it comes as second nature to them rather than thinking out each step as they take it. If you’re just beginning to learn about nursing and nursing theory, understanding the nursing process can help you gain a deeper appreciation for how nurses care for their patients, as well as better prepare you to implement the process into your own nursing process.

What is the nursing process?

The nursing process is a set of steps followed by nurses in order to care for patients. How a particular nurse uses the nursing process varies based on the nurse, the patient, and the situation, but the process generally follows the same steps: assessment, diagnosis, plan, implementation, evaluation.

The first step, assessment, is used to get the patient’s history, as well as a list of symptoms or complaints. Using the information gathered in the assessment, the nurse and other health care professionals can form a diagnosis. The diagnosis is the determination of what’s wrong with the patient, if anything. The assessment and diagnosis allow the nurse to develop a nursing care plan, which is a plan of action for how to care for the patient. This step includes goals set by both the nurse and patient, and determining how best to meet those goals. The implementation sets the nursing care plan in motion in order to meet the patient’s goals.

Finally, the patient is evaluated by the nurse to show whether or not goals were met. Evaluation may be done during the implementation phase in order to make changes to the nursing care plan as needed. For example, if the patient gets worse, he or she may need to be reassessed to come up with a different diagnosis and plan of action. The nurse may also be evaluated at this point to determine how he or she cared for the patient.

Why is the nursing process used?

The nursing process is used to regulate patient care and how nurses interact with patients. By following a particular set of steps in the nursing process, a nurse knows exactly what to do to care for a patient and what comes next.

The nursing process also allows nurses to keep better track of patient care in terms of record-keeping. As a nurse is writing up notes about a patient, he or she can mentally go through the nursing process and make notes about each step. This will help ensure that the nurse does not forget a step or notes about an aspect of patient care, and the rest of a patient’s health care team will be able to follow the process the nurse used, as well.

How are nursing theories applied to the nursing process?

Some nursing models deal directly with the nursing process. That is, these theories guide nurses in how to treat patients from assessment through evaluation. Other nursing theories give a modified version of the nursing process, adapting them to fit the model of nursing. However, there are also nursing theories that don’t apply to the nursing process. These theories may only apply to a specific aspect of nursing, such as assessment, rather than the nursing process as a whole.