A Guide to the Nursing Process: Everything You Need to Know

• The nursing process is something we have all seen before, but what exactly is it?
• There are five components that make up the nursing process: assessment, diagnosis, outcomes/planning, implementation, and evaluation.
• Nursing CE Central has the latest on how you can effectively develop your patient care plans by utilizing the nursing process!

Whether you are in nursing school, a recent grad embarking on your first nursing job, or a seasoned professional in your field, you will use the nursing process time and (time) again throughout your career. 

In nursing school, it’s common for students to be tasked with developing a thorough understanding of the nursing process.

Oftentimes, they are asked to write an effective care plan. However, in a real-world setting, most nurses would laugh if someone asked them to write a care plan solely based on the nursing process.  

So why is this fundamental idea of the nursing process drilled into both student and new nurses‘ minds?  

Think, process. Nursing is about the process.  

What is the Nursing Process?

Simply put, the nursing process is a guide to everything that nurses do. Have you ever thought about it? 

The American Nurses Association defines the nursing process as the “essential core of practice for the registered nurse to deliver holistic, patient-focused care“ and consists of five different components: assessment, diagnosis, outcomes/planning, implementation, and evaluation.  

Although you probably remember seeing these five components during nursing school, the nursing process cannot be fully learned through memorization, but rather through practice and developmental experience. 

Let’s break it down.

Assessment

In order to be able to offer a potential diagnosis, the patient and all external factors must be assessed.

As we mentioned in our blog, listening to a patient and understanding their concerns and hopes for treatment must be the first step in the nursing process.

By doing so, we increase our chances of reaching a diagnosis, developing a treatment plan that meets the patient‘s needs, and increases the overall quality of care given.  

Diagnosis

This phase in the nursing process is one of the most important.

We must consider all external factors of the patient (environmental, socioeconomic, and physiological etc.) when developing a diagnosis, which can be challenging at times.

However, along with your experience and clinical knowledge, there are additional resources available in order to help you!

For example, the North American Nursing Diagnosis Association (NANDA) provides a continuously revised guide of all nursing diagnoses.

Outcomes/Planning

Once you have reached a diagnosis, care panning is the next essential step in the nursing process.

When considering a holistic care approach, it is necessary to factor in the already-determined external factors of the patient and their concerns when setting attainable health goals.

By utilizing resources such as the Nursing Outcomes Classification or Maslow’s Hierarchy of Needs, it can provide insight as to how you should develop a care plan specifically for your patient based on their goals and the level of urgency.

Implementation

This phase involves both direct and indirect patient care, whether that is administering medication, educating the patient, or continuously checking their vitals.

This point in the nursing process should actively follow the care plan that was developed in the previous step and should actively work toward accomplishing the patient‘s health goals.  

Evaluation

Lastly, the evaluation phase should be a direct assessment of if the implemented care plan was effective and if the intended outcomes were reached.

If the goals were not met, you and the patient will re-evaluate and adjust the care plan. 

So How Do We Use It?

The nursing process plays an active role in everyday decision-making.

Over time, it becomes natural and as some would say, it evolves into their “nurse brain.”

The nursing process allows nurses to assess a situation, determine what is happening, change plans, and implement processes all at the drop of a dime. A patient’s status can change at any time so nurses in these situations must utilize the nursing process to make rapid decisions and deliver the best possible outcomes.

Oftentimes, adjustments will need to be made, so nurses must be prepared to adapt to any slight modification. Nurses are pros at expecting the unexpected.

Care Planning

In order to effectively develop a care plan, nurses must first determine their main responsibilities with their patient at the beginning of each shift and by doing so, it outlines the direction and interventions needed for the day.

Your care plan doesn’t have to include any groundbreaking ideas or implementation. However, it must use evidence-based care in conjunction with a holistic approach toward improving the overall health of the patient.

As you can see, the nursing process is implemented into almost every aspect of nursing care, whether we recognize it or not. While in school, did you ever have the thought:

‘Why am I doing this? I am never going to use this in real life.’

Well, everyone, you use the nursing process every day! And it is what sets nurses apart from other professions.

The nursing process makes us masters of the mind.

In what ways do you utilize the nursing process in your practice?

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