The Nursing Process - A Comprehensive Guide - Nurseslabsttt
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In 1958, Ida Jean Orlando began developing the nursing process still evident in nursing care today.
According to Orlando’s theory, the patient’s behavior sets the nursing process in motion. Through the
nurse‘s knowledge to analyze and diagnose the behavior to determine the patient’s needs.
Table of Contents
What is the Nursing Process?
What is the purpose of the nursing process?
Characteristics of the nursing process
Nursing Process Steps
1. Assessment: “What data is collected?”
Collecting Data
Types of Data
Objective Data or Signs
Subjective Data or Symptoms
Verbal Data
Nonverbal Data
Sources of Data
Primary Source
Secondary Source
Tertiary Source
Methods of Data Collection
Health Interview
Physical Examination
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Observation
Validating Data
Documenting Data
2. Diagnosis: “What is the problem?”
3. Planning: “How to manage the problem?”
Types of Planning
Initial Planning
Ongoing Planning
Discharge Planning
Developing a Nursing Care Plan
4. Implementation: “Putting the plan into action!”
Nursing Interventions Classification (NIC) System
Behavioral Nursing Interventions
Community Nursing Interventions
Family Nursing Interventions
Health System Nursing Interventions
Physiological Nursing Interventions
Safety Nursing Interventions
Skills Used in Implementing Nursing Care
Process of Implementing
1. Reassessing the client
2. Determining the nurse’s need for assistance
3. Implementing the nursing interventions
Nursing Intervention Categories
Independent Nursing Interventions
Dependent Nursing Interventions
Interdependent Nursing Interventions
4. Supervising the delegated care
5. Documenting nursing activities
5. Evaluation: “Did the plan work?”
Steps in Evaluation
1. Collecting Data
2. Comparing Data with Desired Outcomes
3. Analyzing Client’s Response Relating to Nursing Activities
4. Identifying Factors Contributing to Success or Failure
5. Continuing, Modifying, or Terminating the Nursing Care Plan
6. Discharge Planning
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The nursing process is defined as a systematic, rational method of planning that guides all nursing
actions in delivering holistic and patient-focused care. The nursing process is a form of scientific
reasoning and requires the nurse’s critical thinking to provide the best care possible to the client.
To identify the client’s health status and actual or potential health care problems or needs
(through assessment).
To establish plans to meet the identified needs.
To deliver specific nursing interventions to meet those needs.
To apply the best available caregiving evidence and promote human functions and responses to
health and illness (ANA, 2010).
To protect nurses against legal problems related to nursing care when the standards of the
nursing process are followed correctly.
To help the nurse perform in a systematically organized way their practice.
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To establish a database about the client’s health status, health concerns, response to illness, and
the ability to manage health care needs.
Patient-centered. The unique approach of the nursing process requires care respectful of and
responsive to the individual patient’s needs, preferences, and values. The nurse functions as a
patient advocate by keeping the patient’s right to practice informed decision-making and
maintaining patient-centered engagement in the health care setting.
Interpersonal. The nursing process provides the basis for the therapeutic process in which the
nurse and patient respect each other as individuals, both of them learning and growing due to
the interaction. It involves the interaction between the nurse and the patient with a common
goal.
Collaborative. The nursing process functions effectively in nursing and inter-professional teams,
promoting open communication, mutual respect, and shared decision-making to achieve quality
patient care.
Dynamic and cyclical.The nursing process is a dynamic, cyclical process in which each phase
interacts with and is influenced by the other phases.
Requires critical thinking. The use of the nursing process requires critical thinking which is a
vital skill required for nurses in identifying client problems and implementing interventions to
promote effective care outcomes.
The steps of the nursing process are not separate entities but overlapping, continuing subprocesses.
Apart from understanding nursing diagnoses and their definitions, the nurse promotes awareness of
defining characteristics and behaviors of the diagnoses, related factors to the selected nursing
diagnoses, and the interventions suited for treating the diagnoses.
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The first phase of the nursing process is assessment. It involves collecting, organizing, validating, and
documenting the clients’ health status. This data can be obtained in a variety of ways. Usually, when
the nurse first encounters a patient, the nurse is expected to assess to identify the patient’s health
problems as well as the physiological, psychological, and emotional state and to establish a database
about the client’s response to health concerns or illness and the ability to manage health care needs.
Critical thinking skills are essential to the assessment, thus requiring concept-based curriculum
changes.
Collecting Data
Data collection is the process of gathering information regarding a client’s health status. The process
must be systematic and continuous in collecting data to prevent the omission of important information
concerning the client.
The best way to collect data is through head-to-toe assessment. Learn more about it at our
guide: Head to Toe Assessment: Complete Physical Assessment Guide
Types of Data
Data collected about a client generally falls into objective or subjective categories, but data can also be
verbal and nonverbal.
Subjective data involve covert information, such as feelings, perceptions, thoughts, sensations, or
concerns that are shared by the patient and can be verified only by the patient, such as nausea, pain,
numbness, pruritus, attitudes, beliefs, values, and perceptions of the health concern and life events.
Verbal Data
Verbal data are spoken or written data such as statements made by the client or by a secondary
source. Verbal data requires the listening skills of the nurse to assess difficulties such as slurring, tone
of voice, assertiveness, anxiety, difficulty in finding the desired word, and flight of ideas.
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Nonverbal Data
Nonverbal data are observable behavior transmitting a message without words, such as the patient’s
body language, general appearance, facial expressions, gestures, eye contact, proxemics (distance),
body language, touch, posture, clothing. Nonverbal data obtained can sometimes be more powerful
than verbal data, as the client’s body language may not be congruent with what they really think or
feel. Obtaining and analyzing nonverbal data can help reinforce other forms of data and understand
what the patient really feels.
Sources of Data
Sources of data can be primary, secondary, and tertiary. The client is the primary source of data,
while family members, support persons, records and reports, other health professionals, laboratory and
diagnostics fall under secondary sources.
Primary Source
The client is the only primary source of data and the only one who can provide subjective data.
Anything the client says or reports to the members of the healthcare team is considered primary.
Secondary Source
A source is considered secondary data if it is provided from someone else other than the client but
within the client’s frame of reference. Information provided by the client’s family or significant others
are considered secondary sources of data if the client cannot speak for themselves, is lacking facts and
understanding, or is a child. Additionally, the client’s records and assessment data from other nurses or
other members of the healthcare team are considered secondary sources of data.
Tertiary Source
Sources from outside the client’s frame of reference are considered tertiary sources of data. Examples
of tertiary data include information from textbooks, medical and nursing journals, drug handbooks,
surveys, and policy and procedural manuals.
Health Interview
The most common approach to gathering important information is through an interview. An interview
is an intended communication or a conversation with a purpose, for example, to obtain or provide
information, identify problems of mutual concern, evaluate change, teach, provide support, or provide
counseling or therapy. One example of the interview is the nursing health history, which is a part of the
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nursing admission assessment. Patient interaction is generally the heaviest during the assessment
phase of the nursing process so rapport must be established during this step.
Physical Examination
Aside from conducting interviews, nurses will perform physical examinations, referencing a patient’s
health history, obtaining a patient’s family history, and general observation can also be used to gather
assessment data. Establishing a good physical assessment would, later on, provide a more accurate
diagnosis, planning, and better interventions and evaluation.
Observation
Observation is an assessment tool that depends on the use of the five senses (sight, touch, hearing,
smell, and taste) to learn information about the client. This information relates to characteristics of the
client’s appearance, functioning, primary relationships, and environment. Although nurses observe
mainly through sight, most of the senses are engaged during careful observations such as smelling
foul odors, hearing or auscultating lung and heart sounds and feeling the pulse rate and other
palpable skin deformations.
Validating Data
Validation is the process of verifying the data to ensure that it is accurate and factual. One way to
validate observations is through “double-checking,” and it allows the nurse to complete the following
tasks:
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Documenting Data
Once all the information has been collected, data can be recorded and sorted. Excellent record-
keeping is fundamental so that all the data gathered is documented and explained in a way that is
accessible to the whole health care team and can be referenced during evaluation.
The types, components, processes, examples, and writing nursing diagnosis are discussed
more in detail here “Nursing Diagnosis Guide: All You Need To Know To Master
Diagnosing”
The planning phase is where goals and outcomes are formulated that directly impact patient care
based on evidence-based practice (EBP) guidelines. These patient-specific goals and the attainment of
such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal
setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique
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needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care
plans enhance communication, documentation, reimbursement, and continuity of care across the
healthcare continuum.
Types of Planning
Planning starts with the first client contact and resumes until the nurse-client relationship ends,
preferably when the client is discharged from the health care facility.
Initial Planning
Initial planning is done by the nurse who conducts the admission assessment. Usually, the same nurse
would be the one to create the initial comprehensive plan of care.
Ongoing Planning
Ongoing planning is done by all the nurses who work with the client. As a nurse obtain new
information and evaluate the client’s responses to care, they can individualize the initial care plan
further. An ongoing care plan also occurs at the beginning of a shift. Ongoing planning allows the
nurse to:
Discharge Planning
Discharge planning is the process of anticipating and planning for needs after discharge. To provide
continuity of care, nurses need to accomplish the following:
Start discharge planning for all clients when they are admitted to any health care setting.
Involve the client and the client’s family or support persons in the planning process.
Collaborate with other health care professionals as needed to ensure that biopsychosocial,
cultural, and spiritual needs are met.
The planning step of the nursing process is discussed in detail in Nursing Care Plans
(NCP): Ultimate Guide and Database.
Interventions should be specific to each patient and focus on achievable outcomes. Actions associated
with a nursing care plan include monitoring the patient for signs of change or improvement, directly
caring for the patient or conducting important medical tasks such as medication administration,
educating and guiding the patient about further health management, and referring or contacting the
patient for a follow-up.
These are interventions designed to help a patient change their behavior. With behavioral
interventions, in contrast, patient behavior is the key and the goal is to modify it. The following
measures are examples of behavioral nursing interventions:
These are interventions that refer to the community-wide approach to health behavior change. Instead
of focusing mainly on the individual as a change agent, community interventionists recognize a host of
other factors that contribute to an individual’s capacity to achieve optimal health, such as:
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Implementing a family-centered approach in reducing the threat of illness spreading when one
family member is diagnosed with a communicable disease
Providing a nursing woman support in breastfeeding her new baby
Educating family members about caring for the patient
These are interventions that designed to maintain a safe medical facility for all patients and staff, such
as:
Following procedures to reduce the risk of infection for patients during hospital stays.
Ensuring that the patient’s environment is safe and comfortable, such as repositioning them to
avoid pressure ulcers in bed
These are interventions related to a patient’s physical health to make sure that any physical needs are
being met and that the patient is in a healthy condition. These nursing interventions are classified into
two types: basic and complex.
Basic. Basic interventions regarding the patient’s physical health include hands-on procedures
ranging from feeding to hygiene assistance.
Complex. Some physiological nursing interventions are more complex, such as the insertion of
an IV line to administer fluids to a dehydrated patient.
These are interventions that maintain a patient’s safety and prevent injuries, such as:
Educating a patient about how to call for assistance if they are not able to safely move around
on their own
Providing instructions for using assistive devices such as walkers or canes, or how to take a
shower safely.
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Cognitive Skills are also known as Intellectual Skills are skills involve learning and
understanding fundamental knowledge including basic sciences, nursing procedures, and their
underlying rationale before caring for clients. Cognitive skills also include problem-solving,
decision-making, critical thinking, clinical reasoning, and creativity.
Interpersonal Skills are skills that involve believing, behaving, and relating to others. The
effectiveness of a nursing action usually leans mainly on the nurse’s ability to communicate with
the patient and the members of the health care team.
Technical Skills are purposeful “hands-on” skills such as changing a sterile dressing,
administering an injection, manipulating equipment, bandaging, moving, lifting, and
repositioning clients. All of these activities require safe and competent performance.
Process of Implementing
The process of implementing typically includes the following:
Prior to implementing an intervention, the nurse must reassess the client to make sure the intervention
is still needed. Even if an order is written on the care plan, the client’s condition may have changed.
Other nursing tasks or activities may also be performed by non-RN members of the healthcare team.
Members of this team may include unlicensed assistive personnel (UAP) and caregivers, as well as
other licensed healthcare workers, such as licensed practical nurses/licensed vocational nurses
(LPNs/LVNs). The nurse may need assistance when implementing some nursing intervention, such as
ambulating an unsteady obese client, repositioning a client, or when a nurse is not familiar with a
particular model of traction equipment needs assistance the first time it is applied.
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Nursing interventions are grouped into three categories according to the role of the healthcare
professional involved in the patient’s care:
A registered nurse can perform independent interventions on their own without the help or assistance
from other medical personnel, such as:
A nurse performs as part of collaborative or interdependent interventions that involve team members
across disciplines.
In some cases, such as post-surgery, the patient’s recovery plan may require prescription
medication from a physician, feeding assistance from a nurse, and treatment by a physical
therapist or occupational therapist.
The physician may prescribe a specific diet to a patient. The nurse includes diet counseling in
the patient care plan. To aid the patient, even more, the nurse enlists the help of the dietician
that is available in the facility.
Delegate specific nursing interventions to other members of the nursing team as appropriate. Consider
the capabilities and limitations of the members of the nursing team and supervise the performance of
the nursing interventions. Deciding whether delegation is indicated is another activity that arises
during the nursing process.
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The American Nurses Association and the National Council of State Boards of Nursing (2006) define
delegation as “the process for a nurse to direct another person to perform nursing tasks and
activities.” It generally concerns the appointment of the performance of activities or tasks associated
with patient care to unlicensed assistive personnel while retaining accountability for the outcome.
Nevertheless, registered nurses cannot delegate responsibilities related to making nursing judgments.
Examples of nursing activities that cannot be delegated to unlicensed assistive personnel include
assessment and evaluation of the impact of interventions on care provided to the patient.
Steps in Evaluation
Nursing evaluation includes (1) collecting data, (2) comparing collected data with desired outcomes, (3)
analyzing client’s response relating to nursing activities, (4) identifying factors that contributed to the
success or failure of the care plan, (5) continuing, modifying, or terminating the nursing care plan, and
(6) planning for future nursing care.
1. Collecting Data
The nurse recollects data so that conclusions can be drawn about whether goals have been fulfilled. It
is usually vital to collect both objective and subjective data. Data must be documented concisely and
accurately to facilitate the next part of the evaluating process.
The goal was met, when the client response is the same as the desired outcome.
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The goal was partially met, when either a short-term outcome was achieved but the long-term
goal was not, or the desired goal was incompletely attained.
The goal was not met.
It is also very important to determine whether the nursing activities had any relation to the outcomes
whether it was successfully accomplished or not.
It is required to collect more data to confirm if the plan was successful or a failure. Different factors
may contribute to the achievement of goals. For example, the client’s family may or may not be
supportive, or the client may be uncooperative to perform such activities.
The nursing process is dynamic and cyclical. If goals were not sufficed, the nursing process begins
again from the first step. Reassessment and modification may continually be needed to keep them
current and relevant depending upon general patient condition. The plan of care may be adjusted
based on new assessment data. Problems may arise or change accordingly. As clients complete their
goals, new goals are set. If goals remain unmet, nurses must evaluate the reasons these goals are not
being achieved and recommend revisions to the nursing care plan.
6. Discharge Planning
Discharge planning is the process of transitioning a patient from one level of care to the next.
Discharge plans are individualized instructions provided as the client is prepared for continued care
outside the healthcare facility or for independent living at home. The main purpose of a discharge plan
is to improve the client’s quality of life by ensuring continuity of care together with the client’s family
or other healthcare workers providing continuing care.
The following are the key elements of IDEAL discharge planning according to the Agency for
Healthcare Research and Quality:
Include the patient and family as full partners in the discharge planning process.
Discuss with the patient and family five key areas to prevent problems at home:
Describe what life at home will be like
Review medications
Highlight warning signs and problems
Explain test results
Schedule follow-up appointments
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Educate the patient and family in plain language about the patient’s condition, the discharge
process, and next steps throughout the hospital stay.
Assess how well doctors and nurses explain the diagnosis, condition, and next steps in the
patient’s care to the patient and family and use teach back.
Listen to and honor the patient’s and family’s goals, preferences, observations, and concerns.
A discharge plan includes specific components of client teaching with documentation such as:
Equipment needed at home. Coordinate home-based care and special equipment needed.
Dietary needs or special diet. Discuss what the patient can or cannot eat at home.
Medications to be taken at home. List the patient’s medications and discuss the purpose of
each medicine, how much to take, how to take it, and potential side effects.
Resources such as contact numbers and addresses of important people. Write down the
name and contact information of someone to call if there is a problem.
Emergency response: Danger signs. Identify and educate patients and families about warning
signs or potential problems.
Home care activities. Educate patient on what activities to do or avoid at home.
Summary. Discuss with the patient and family about the patient’s condition, the discharge
process, and follow-up checkups.
Jeremy
January 27, 2022 at 12:45 AM
Nourece
February 11, 2022 at 3:41 AM
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So helpful
And easy to understand
A very good guide for nurses
Reply
Nadine O.
February 5, 2022 at 9:38 AM
I’m a clinical instructor teaching Fundamentals this semester. The article will be very helpful to
give an in-depth explanation of “The Nursing Process” to students. Thank you.
Reply
BRENDA AMITO
March 11, 2022 at 1:05 PM
Janeth
April 22, 2022 at 3:55 PM
This is so helpful
Reply
Thank you!
Reply
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Joeanna Curry
August 13, 2022 at 10:05 PM
Saraha
August 31, 2022 at 9:32 AM
Kendi
September 5, 2022 at 1:45 PM
Carmelle Dorsaint
December 28, 2022 at 7:09 AM
Helpful. So grateful
Reply
Julie
March 28, 2023 at 5:13 PM
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Reply
Octavia daki
April 9, 2023 at 9:05 PM
Allu micah
July 9, 2023 at 4:32 PM
Edna
July 15, 2023 at 7:52 PM
Sabrina
September 27, 2023 at 4:47 AM
I agree
Reply
JOYCELYN
October 24, 2023 at 7:25 AM
Excellent job. A great help to all nursing students. Thank you for sharing. God bless you.
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Reply
Hi Joycelyn,
Thank you so much for your kind words! It’s really rewarding to hear that it’s helping nursing
students out there. We’re all about sharing knowledge and making things a bit easier. 😊 If
there’s anything else you’d like to see or know, just let me know. And blessings right back at
you!
Reply
A. C
November 16, 2023 at 4:58 AM
You’re very welcome, A.C! I’m glad you found the nursing process reference comprehensive
and useful. Just out of curiosity, is there a particular step in the nursing process you’d like to
explore more deeply, or do you have any specific areas where you’d like more detailed
information?
Reply
mawuli
December 19, 2023 at 9:58 AM
I am a nursing student and I see this as a helpful tool, very detailed and easy to understand
thanks for sharing
Reply
Hi Mawuli, I’m delighted to know that you’re finding our resources helpful! If you have any
specific questions or if there’s a particular topic you’d like more information on, please feel
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free to ask. I’m here to assist you with any nursing-related inquiries you may have. Keep up
the great work in your studies! 🩺📚🌟
Reply
Mokete
December 20, 2023 at 4:02 AM
Hey Mokete, Thank you so much for the kind words! We’re thrilled to hear that you’re finding
our nursing resources helpful. We’ll do our best to keep you updated with more valuable
nursing PDFs and information. If there’s anything specific you’d like to see or if you have any
questions, feel free to let us know. Keep up the great work in your nursing journey! 👩⚕️📚🌟
Reply
Aminu subash
December 22, 2023 at 11:29 AM
Berhane Hadera
December 28, 2023 at 9:01 AM
This guideline very useful for Nurses building their competency and practice quality of care of
Nursing to use as reference please allow to download free especially to Nurses who live in
developing countries since it is not affordable to buy it
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thank you
Reply
You can download the articles by printing them as PDF :) You can use a service called
printfriendly (google it) to make PDFs of our webpages.
Reply
MusaGibril
January 16, 2024 at 7:38 PM
Muzamil Ali
January 16, 2024 at 10:10 PM
Good 👍
Reply
Theophilus Baah
January 17, 2024 at 9:21 PM
Hello Theophilus, You’re very welcome, and thank you for the blessings! 😊 I’m glad you
found the reference on the nursing process comprehensive. Just out of curiosity, is there a
particular part of the nursing process you’re most interested in, or any aspect you’d like to
explore more deeply?
God bless you too, and if you have any more questions, feel free to ask!
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Reply
Thank you so much, Alisa. If you need more information or help regarding this, let us know.
Reply
Millicent Vadze
February 22, 2024 at 9:53 PM
Hi Millicent, Thank you so much for the kind words! 😊 I’m really glad you’re finding the site
useful.
Regarding your request to download content as a PDF, a neat trick you can use is the “print”
function in your web browser. Here’s how you can do it:
Open the page you want to save as a PDF.
-Go to the “File” menu in your browser and select “Print,” or simply press Ctrl+P (Cmd+P on
Mac).
-In the print window, look for a destination option and select “Save as PDF” or something
similar.
-Adjust any settings as needed, then click “Save” or “Print,” and choose where you want to
save the file on your computer.
This way, you can turn any page into a PDF for your personal use. If you have any more
questions or need further assistance, feel free to ask. Always here to help!
Reply
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Aneena Johny
April 21, 2024 at 9:39 AM
Very helpful
Thank you
Reply
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