Implementing the Nursing Process Standards of Care

Quality of nursing care can make the difference between life and death. The nursing process is a blueprint that builds good care and improves patient outcomes. Nurses use five steps to gather and interpret information. Assessment, diagnosis, planning, implementation and evaluation contribute to the health of patients and help them cope with illness. Reviewing the nursing process can lead to better patient understanding and improved problem-solving skills for the healthcare team. (Reference 3, Page 1, "Benefits and Characteristics of the Nursing Process")

Instructions

Five Steps in the Nursing Process

• 1

  The nurse examines and interviews the patient.

  Gather relevant information about the problem or condition. The assessment phase of the nursing process consists of collecting and analyzing information. The assessment is divided into two parts:

  a. Subjective data based on patient responses to interview questions and descriptions of pain.

  b. Objective date based on diagnostic testing as well as measurements and observations attained during examination. (See Reference 1, section 1-data collection)

• 2

  The doctor and the nurse diagnose the patient.

  Identify and name the problem. In the diagnosis process, the nurse identifies either the patient's actual or risked response to a health problem while the doctor names the disease or condition causing the problem. After diagnosis, the healthcare team provides relief and promotes healing. (Resource 1, Slide 2 and 6)

• 3

  The medical team makes a plan.

  Make a schedule and list of actions to take. The nurse devises a plan and determines how to effectively treat the health problem. She identifies the most important aspects of the care plan and includes expected results. (Reference 2, page 12)

• 4

  The healthcare providers take action.

  Intervene, and act to combat the disease process, relieve pain, and maintain health. The nurse follows the nursing care plan. She combines the medical care prescribed by the physician with her nursing care. (Reference 3, page 2 - step 3 and page 7, "classification of interventions")

• 5

  Medical personnel evaluate the results of treatment.

  Evaluate the results and determine whether to change the treatment. The nurse evaluates the outcome of her care, identifying and correcting any misdiagnoses or ineffective treatment. The nurse sets goals that are observable, measurable, and in compliance with a deadline. (Page 6 and 7 of Reference 3)