As a nurse, your primary duty is to ensure that your patient gets proper care. Whilst on duty, you will collect and analyze the patient’s information. You have to appropriately use this information. But what are the steps of nursing in the nursing process? The steps of the nursing process are an ideal guideline for nurses to follow to ensure that the nurse meets all the patient’s needs. In this blog, you will learn about the steps of the nursing process and how to execute them.

What do the nursing process steps aim to achieve?

The goal of the nursing process is to create a standard of care where nurses evaluate patients and develop plans of action to meet each patient’s specific needs. There are still more goals for the steps of the nursing process, including but not limited to the ones listed below.

• Creates plans to address the requirements of patients
• Safeguards nurses from potential legal issues
• Helps nurses provide high-quality, evidence-based care.

Encourages the use of a systematic approach to patient care that the entire nursing team may adhere to.

Features of the steps of the nursing process

Here are the unique features of the nursing process

Cyclical and dynamic

 Each step in the nursing process interacts and is influenced by other areas.

Interpersonal

The nursing process offers a foundation for a therapeutic process. The patient and nurse learn from each other as they keep interacting with a common goal.

Patient-focused

Nursing process steps necessitate a nurse being responsive and respectful to a patient’s needs, values, and preferences. The role of a nurse is similar to that of an advocate. They should help the patient make informed decisions and maintain a patient-focused decision.

Critical thinking

The nursing process necessitates critical thinking, essential skill nurses need to find problems and implement the strategies required to ensure quality care outcomes.

Teamwork

The steps of the nursing process are effective when the nurse and other related professional teams work together, promoting shared decisions and making respectful and open communication to achieve the best quality healthcare

Based on reliable information

The nurse must apply nursing knowledge and abilities to recognize issues and find solutions to employ the nursing process effectively. Implementing evidence-based care processes and developing critical thinking abilities in nurses should be continually prioritized.

Within the bounds of the law

The fact that the nursing process must be used within the nurse’s legal practice limits could arguably be its most important quality.

Goal-directed

Target-directed care, as the name implies, provides nursing care based on accomplishing personal objectives to achieve desired patient outcomes. Nursing staff, patients, and other healthcare team members work together to set goals.

Prioritized

Prioritizing patient care and concentrating on the most critical conditions requires identifying all health issues and risk factors. As you study the steps of the nursing process in order.

Planned

A nursing process is a systemic approach to patient care that is provided effectively and in the correct order. The priority order of the care plan may vary as further assessments and evaluations are conducted, depending on how the patients respond to treatment.

The five steps of the nursing process

The big question is, what are the steps of the nursing process? The nursing process is a five-step process that helps to guide nurses to provide quality healthcare. The steps of the nursing process are essentially taught during the nursing course, and nurses employ these steps informally when carrying out daily activities.

The nurse must use professional judgment to develop a basic daily strategy when determining how a shift will proceed with patients. The nursing process enables the nurse to learn about each patient, rank their issues, and establish goals. As nurses get more expertise, using the nursing process when making choices about patient care becomes second nature. Here are the steps of the nursing process in order

1. Assessment phase

The nurse will look at the objective and subjective data collected on the assessment pages. The main idea in this phase is to gain all this information and assess the client’s health situation. You will start the assessment phase before seeing the patients and carry on through your entire shift.

Data Collection methods in the assessment phase

The three basic techniques for gathering data are physical examinations, health interviews, and observation.

Physical Examination

In addition to conducting interviews, nurses will perform physical examinations and consult a patient’s medical history. Ask about their family history, and make general observations to collect assessment data. A sound physical assessment would enable more precise diagnosis, planning, interventions, and evaluation.

Interview

This is a pretty standard approach to gaining essential information in interviews. The main objective of an interview is to gain or offer information, find problems, find problems, and provide support or therapy.

Observation

Observation is a simple assessment tool that relies on the senses of smell to gather patient information. The information you will gain is mainly about the patient’s functioning, primary relationships, and the environment.

Validating Data

Validation is the process of confirming the data’s accuracy and verifiability. The nurse can carry out the following procedures by “double-checking” observations as a way to validate them:

• Verify the validity and accuracy of all relevant factual and subjective data
• Recognize the difference between clues and inferences
• Make sure to clarify any assertions that are unclear or ambiguous
• Assures the accuracy, completeness, and verification of assessment data
• Obtain additional information that may have been missed
• Make sure the nurse doesn’t conclude without sufficient evidence to back it up

Documenting Data

Data can be recorded and arranged once all the necessary information has been gathered. Impressive record is essential to ensure that all the information collected is documented, explained, and available to the entire nursing staff for use in evaluation.

2. Diagnosis phase

In the diagnosis steps of the nursing process, you need to take the results so your assessments and create several nursing diagnoses that will dictate how you will care for the patient during the shift. Remember that a nursing diagnosis differs from a medical diagnosis and is subjectively based on your judgment. Nursing diagnosis is focused on addressing the problems patients face during their shifts.

When you create a nursing diagnosis, you prioritize the patient’s needs. Given that each patient has unique issues, the best solution is to follow Maslow’s hierarchy of needs. Creating a nursing diagnosis based on your information will help you stay alert for any challenges you can anticipate.

3. Planning phase

The outcome phase, also known as the planning phase, is the stage that helps nurses create a plan of action. In this phase, you should structure your plan of action. What do you intend to do during your shift? Keep in mind that safety is the main priority. Prioritize things like the airway and breathing, among others. For each of the medical concerns, ensure you have specific goals and create a plan on how to achieve that.

Types of planning

The planning phase begins immediately when the nurse makes the first contact and ends when the patient leaves the hospital or medical facility.

Initial Planning

The initial is done by the nurse who conducts the initial admission assessment

Ongoing Planning

A nurse who works with the client is responsible for continuing planning. You can get new information and evaluate the client’s response to care. You can customize the initial care plan further.

• Ascertain whether the client’s health status has altered.
• Decide which issues to prioritize for the client during the shift
• Liaise with nurses to make sure that several issues may be handled during each client interaction

Discharge Planning

Discharge planning is the process of anticipating and planning for needs after discharge. To provide continuity of healthcare, nurses need to accomplish the following:

• Include the client, family members, or other supporters in the planning process.
• When a patient is hospitalized at a healthcare facility, the planning for their discharge should begin.
• Work with other medical specialists to meet patients’ biopsychosocial, cultural, and spiritual requirements.

4. Implementing phase

What steps would you take to ensure you achieve these objectives? You’ll design a few nursing interventions throughout the implementation phase to assist the patient in achieving their objectives. After dealing with breathing and airway issues, you can come up with more action items that will aid in attaining the planning phase’s objectives.

Nursing care implementation skills

To successfully carry out the care plan, nurses need cognitive, interpersonal, and technical abilities.

Interpersonal skills are those that have to do with how you think, act, and relate to other people. The efficiency of a nursing intervention typically depends mainly on the nurse’s aptitude for interaction with the patient and the other healthcare team members.

Cognitive Skills: Before providing client care, cognitive skills, often referred to as intellectual skills, require acquiring fundamental knowledge, such as understanding the basic science and the rationale behind nursing practices. Judgment, Problem-solving, clinical reasoning, creativity, and critical thinking are more examples of cognitive capabilities.

Technical skills include deliberate “hands-on” abilities, including operating machinery, injecting patients, changing sterile dressings, repositioning patients, moving, lifting, and bandaging. All of these tasks must be carried out safely and effectively.

5. Evaluation phase

The evaluation phase is the last step in the nursing process. It occurs after the interventions to determine whether the objectives were achieved. The nurse will decide how to assess the efficacy of the goals and interventions during the evaluation phase.

Steps in Evaluation

Nursing evaluation includes:

1. Collecting data

The nurse gathers information to judge whether you have met the objectives. The collection of both objective and subjective data is typically essential. The data must be concise and precise to make the next step of the evaluation in the nursing process easier.

2. Comparing data against preferred Outcomes

Whether the targeted outcome has been entirely, partially, or not attained, the patient’s progress is evaluated by the nursing care plan’s specified aims and objectives.

3. Evaluating the client’s response to nursing interventions

Determining if the nursing actions had any bearing on the results, regardless of whether they were completed successfully or not, is also crucial.

Understanding the Elements that Affect Success or Failure

More information must be gathered to determine whether the plan was successful. A variety of circumstances may influence the accomplishment of goals. For instance, the client’s family may or may not be helpful, or the client may not want to engage in these activities.

Continue, Change, or End the Nursing Care Plan

Nursing is a fluid and circular process. If you didn’t meet the goals, the nursing process starts at step one. Based on the overall patient status, they may need to be regularly reevaluated and modified to be relevant.

Based on new assessment results, the care plan might be changed. Issues might develop or evolve in such a way. New targets are set as the clients reach their existing ones. If objectives are not fulfilled, nurses must assess why they are not being met and suggest changes to the nursing care plan.

Discharge Planning

Planning for a patient’s discharge from one care setting to another is known as “discharge planning.” Discharge plans are tailored sets of guidelines given to patients as they near readiness for either independent living or to continue receiving care elsewhere.

A discharge plan’s primary objective is to enhance the client’s quality of life by facilitating continued care coordination between the healthcare team, the client’s family, and any other relevant care providers.

The bottom line

The nursing process is a dynamic and cyclic step. As a nurse, you need to come up with goals and find a solution or creativity to meet the ultimate goal which find the best quality healthcare for the patient. In the steps of the nursing process, from the assessment phase to the evaluation phase, you need to stay alert and incorporate your nursing skills and find problems find solutions and help the patient, and at the same time communicate effectively with other members of the nursing staff.