The nursing process is a systematic and scientific method used by nurses to plan and provide care for patients. It is a patient-centered, goal-directed, and organized framework that ensures the delivery of safe, effective, and individualized nursing care. This process enables nurses to think critically, make decisions, and solve problems related to patient health. It forms the core of nursing practice across all settings—hospitals, communities, and homes—and helps establish a strong nurse-patient relationship through effective communication and assessment.
Definition:
The nursing process is defined as:
“A deliberate, problem-solving, and decision-making method that nurses use to identify and meet the needs of patients in a structured, logical sequence.”
It is a five-step process involving:
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
These steps ensure that care is continuous, coordinated, and responsive to patient needs.
Purposes of Nursing Process
The nursing process serves multiple essential purposes in nursing care. It provides a framework for delivering safe, efficient, and patient-centered care. Below are the main purposes:
- To Identify Patient Needs:
Helps nurses systematically assess and understand the physical, emotional, social, and spiritual needs of the patient. - To Provide Individualized Care:
Enables nurses to plan care based on each patient’s specific condition, preferences, and responses. - To Promote Evidence-Based Practice:
Ensures that nursing interventions are based on research, clinical knowledge, and best practices. - To Enhance Communication:
Facilitates clear communication among nurses and other healthcare professionals by using a common framework and language. - To Improve Patient Outcomes:
Promotes consistent and goal-oriented care that leads to better recovery, comfort, and satisfaction. - To Encourage Critical Thinking:
Engages nurses in analyzing patient data and making thoughtful decisions, which improves clinical judgment. - To Provide a Basis for Documentation:
Offers a structure for recording all aspects of patient care in a clear and organized way. - To Promote Continuity of Care:
Ensures that care is coordinated and consistent across shifts and among team members. - To Evaluate Effectiveness of Care:
Helps nurses assess whether the patient goals are being met and if care plans need adjustment. - To Ensure Legal and Professional Accountability:
Documents nursing actions and decisions, which are important for legal protection and professional standards.
5 Steps of the Nursing Process
1. Assessment
The first step in the nursing process is assessment. This is where the nurse collects detailed and holistic information about the patient’s condition.
What happens in this step?
Nurses gather:
- Subjective data – What the patient says (e.g., “I feel dizzy.”)
- Objective data – What the nurse observes (e.g., vital signs, physical exam, test results)
Methods of assessment include:
- Patient interviews
- Physical examinations
- Observations
- Reviewing medical history and records
2. Diagnosis
After collecting and analyzing data, the nurse moves on to nursing diagnosis—not to be confused with a medical diagnosis. Here, the nurse identifies the patient’s problems or potential risks that nursing care can address.
Types of nursing diagnoses:
- Actual diagnoses (e.g., Impaired physical mobility)
- Risk diagnoses (e.g., Risk for infection)
- Wellness diagnoses (e.g., Readiness for enhanced coping)
Nurses use the NANDA (North American Nursing Diagnosis Association) format to write standardized and clear diagnoses.
Example:
“Impaired skin integrity related to immobility as evidenced by pressure ulcers.”
This step helps nurses prioritize care based on real patient needs.
3. Planning
Once the problems are identified, it’s time to plan the care. This third step involves creating a personalized care plan that addresses each nursing diagnosis.
Key elements of planning:
- Setting priorities – Address life-threatening issues first
- Establishing SMART goals – Specific, Measurable, Achievable, Relevant, and Time-bound
- Choosing nursing interventions – Evidence-based actions tailored to the patient
Example goal:
“Patient will maintain oxygen saturation above 95% within 24 hours.”
4. Implementation
Now comes the action phase. Implementation is where the nurse carries out the planned interventions to meet the patient’s goals.
Types of nursing interventions:
- Independent – Nurse-initiated (e.g., repositioning the patient)
- Dependent – Ordered by a physician (e.g., giving medication)
- Collaborative – Done with other professionals (e.g., physical therapy)
5. Evaluation
Finally, the nurse evaluates the effectiveness of the care provided. Did the patient improve? Were the goals met?
Evaluation involves:
- Comparing outcomes with goals
- Reviewing patient responses
- Modifying the care plan if necessary
Example:
If the goal was to reduce fever and the temperature remains high, the nurse may adjust interventions or consult with the healthcare team again.
This final step ensures ongoing quality of care and helps in updating the care plan as the patient’s condition evolves.