What is the 3rd step in the nursing process?

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Characteristics of Nursing Process
Components of Nursing Process
Nursing Assessment
Nursing Diagnosis
Nursing Planning and Outcome Identification
Identifying outcomes
Expected outcomes
Problems during planning
Planning for nursing intervention
Types of nursing interventions
Documenting the intervention

The nursing process is the framework for providing professional, quality nursing care. It directs nursing activities for health promotion, health protection, and disease prevention and is used by nurses in every practice setting and specialty.

Characteristics of Nursing Process

A process is a series of steps or acts that lead to accomplishing some goal or purpose. Processes have three characteristics: 1. Inherent purpose. 2. Internal organization. 3. Infinite creativity.

Components of Nursing Process

The nursing process is a systematic method for providing care to clients. The nursing process is dynamic and requires creativity in its application. The steps are the same for each client situation, but the correlation and results will be different. The nursing process is used with clients of all ages and in any care setting

Nursing Assessment

The first step in the nursing process includes systematic collection, verification, organization, interpretation, and documentation of data. The completeness and correctness of this data relate directly to the accuracy of the steps that follow.

• Data collection from a variety of sources

• Data validation

• Data organization

• Data interpretation

• Data documentation

Nursing Diagnosis

The second step in the nursing process involves further analysis (breaking down the whole into parts that can be examined) and synthesis (putting data together in a new way) of the collected data. A list of nursing diagnoses is the result of this process.According to NANDA-International, a nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. Clients have both medical and nursing diagnoses.

Analysis of the collected data leads the nurse to make a diagnosis in one of three categories:

• An actual nursing diagnosis: indicates that a problem exists; it is composed of the diagnostic label, related factors, and signs and symptoms.

• Arisk nursing diagnosis (potential problem): indicates that a problem does not yet exist but that specific risk factors are present. Risk for followed by the diagnostic label and a list of the risk factors.

• A wellness Nursing Diagnosis: denotes the client’s statement of a desire to attain a higher level of wellness in some area of function. It begins with the phrase Readiness for Enhanced followed by the diagnostic label

Nursing Planning and Outcome Identification

Planning and outcome identification are the third step of the nursing process and include both establishing guidelines for the proposed course of nursing action to resolve the nursing diagnoses and developing the client’s plan of care. The planning occurs in three phases: initial, ongoing, and discharge.

1. Initial planning: involves development of a preliminary plan of care by the nurse who performs the admission assessment and gathers the comprehensive admission assessment data. Progressively shorter stays in the hospital make initial planning very important to ensure resolution of the problems.

2. Ongoing planning: updates the client’s plan of care. New information about the client is collected and evaluated and revisions made to the plan of care.

3. Discharge planning: involves anticipation of and planning for the client’s needs after discharge.

Nursing Implementation

The fourth step in the nursing process is implementation, the performance of the nursing interventions identified during the planning phase. It also involves the delegation (process of transferring a select nursing task to a licensed individual who is competent to perform that specific task) of some nursing interventions to staff members or assigning a specific nursing task to assistive (unlicensed) personnel capable of competently performing the task. The nurse is accountable for appropriate delegation and supervision of care provided by unlicensed personnel.

Nursing Evaluation

Evaluation, the fifth step in the nursing process, determines whether client goals have been met, partially met, or not met. When a goal is met, the nurse decides whether nursing interventions should stop or continue for the status to be maintained. When a goal is partially met or not met, the nurse reassesses the situation. The reasons the goal is not met and modifications to the plan of care are determined by more data collection. Reasons that goals are not met or are only partially met include:

• Initial assessment data were incomplete.

• Goals and expected outcomes were unrealistic.

• Time frame was not adequate.

• Nursing interventions were not appropriate for the client or situation. Evaluation is a fluid process that depends on all the other components of the nursing process

Planning and outcome identification is the third step of the nursing process and includes both establishing guidelines for the proposed course of nursing action to resolve the nursing diagnoses and developing the client’s plan of care. After the nursing diagnoses and the client’s strengths have been identified, planning begins.

The planning occurs in three phases: initial, ongoing, and discharge. Initial planning involves the development of a preliminary plan of care by the nurse who performs the admission assessment and gathers the comprehensive admission assessment data. Progressively shorter stays in the hospital make initial planning very important to ensure resolution of the problems.

Ongoing planning updates the client’s plan of care. New information about the client is collected and evaluated and revisions made to the plan of care.

Discharge planning involves anticipation of and planning for the client’s needs after discharge.

The planning phase involves several tasks:

Prioritizing the nursing diagnoses
Identifying and writing client-centred long and short-term goals and outcomes (outcome identification)
Identifying specific nursing interventions
Recording the entire nursing care plan in the client’s record

Once the list of nursing diagnoses has been developed from the data, decisions must be made about priority. Critical thinking enables the nurse to make decisions about which diagnoses are the most important and need attention first. There are a number of frameworks used to prioritize nursing diagnoses; however, those diagnoses involving life-threatening situations are given the highest priority.

An additional point regarding the establishment of priorities is the anticipation of future diagnoses. Nursing diagnoses of low and moderate priorities often involve the prevention of anticipated potential or risk diagnoses. Although potential nursing diagnoses may not be a current threat to the client, their seriousness may require that the nurse consider the development of nursing interventions directed toward prevention of the problem.

For example, a client in the Postanesthesia Care Unit may have a high-priority nursing diagnosis of Ineffective Breathing Pattern related to anaesthesia and sedative drugs. Despite the fact that the client currently has no problem in this area, this diagnosis is indeed the basis for the Postanesthesia Care Unit protocol of monitoring the client closely.

Identifying outcomes

Goals: A goal is an aim, intent, or end. Goals are broad statements that describe the desired or intended change in the client’s condition or behaviour. Client-centred goals are established in collaboration with the client when possible. Goal statements refer to the diagnostic label of the nursing diagnosis. Client-centred goals ensure that nursing care is individualized and focused on the client.

A goal is of two types i.e. i) Short term goal and ii) Long term goal

A short-term goal is a statement that profiles the desired resolution of the nursing diagnosis over a short period of time, usually a few hours or days (less than a week). It focuses on the aetiology part of the nursing diagnosis.

A long-term goal is a statement that profiles the desired resolution of the nursing diagnosis over a longer period of time, usually weeks or months. It focuses on the problem part of the nursing diagnosis.

For example A client with depression who had a leg amputation, the short term goal will be client will verbalise his feelings. Long term goal is will be client will accept his amputation and take the initiatives to do the daily livings work with prosthetics.

Expected outcomes

Expected Outcomes After the goals have been established, the expected outcomes can be identified based on those goals. An expected outcome is a detailed, specific statement describing the methods to be used to achieve the goal. It includes direct nursing care, client teaching, and continuity of care. Outcomes must be measurable, realistic, and time-limited.

Problems during planning

Nursing students, as beginners in the use of the nursing process, often fall into some common pitfalls when applying the steps to practice. These pitfalls are described with the intent of providing a clear direction for the use of this process and proposing suggestions for avoiding these common errors.

In regard to writing goals, the errors frequently observed in this component involve improper format. Format errors include goals that are nurse-centred instead of client-centred, unrealistic, negative rather than positive, generically copied from a reference and not individualized to the client, unmeasurable, nonspecific, nonbehavioral, vague, wordy, and without a time frame.

Another challenge in the development of goals and expected outcomes is the establishment of appropriate time frames for the accomplishment of the intended results. Although this component may be difficult at first to master, nursing professionals should practice writing goals that are realistic and include appropriate time frames using available literature and resources to gain expertise. It is preferable for a goal to include an excessively short, rather than an excessively long, time frame because the goal is brought to attention in the evaluation process more frequently.

By inserting the time frame “daily” for specific goals, the expected outcome will be brought up frequently for evaluation. Through a process of building on continued professional growth and experience.

Planning for nursing intervention

Once the goals have been mutually agreed on by the nurse and client, the nurse should use a decision-making process to select appropriate nursing interventions. Nursing intervention is an action performed by a nurse that helps the client to achieve the results specified by the goals and expected outcome. These terms are based on scientific principles and knowledge from behavioural and physical sciences.

The effective nurse plans interventions that are directed toward the cause of the client’s nursing diagnosis or problem.

For example, for a client with angina who may have the nursing diagnosis of Pain related to myocardial ischemia, an appropriate nursing intervention would be to help the client conserve energy (i.e., bedrest).

In determining which nursing interventions to use, the nurse should critically consider the consequences and the risks of each intervention. After considering these factors, the nurse selects those that are most likely to be effective with the minimum of risk.

After setting the goals and planning the appropriate nursing interventions, the nurse writes nursing orders to communicate the exact nursing interventions that are to be implemented for the client. A nursing order is a statement written by the nurse that is within the realm of nursing practice to plan and initiate. These statements specify the direction and individualize the client’s plan of care.

Types of nursing interventions

Nursing interventions are classified into one of three categories: independent, interdependent, or dependent.

Independent nursing interventions are initiated by the nurse and do not require direction or order from another health care professional. In most areas nursing personnel practice independent nursing interventions for activities such as daily living, health education, health promotion, and counselling. An example of independent nursing intervention is elevating a client’s edematous extremity.

Interdependent nursing interventions are implemented collaboratively by the nurse in addition to other health care professionals. For example, the nurse may assist a client to perform an exercise taught by the physical therapist.

Dependent nursing interventions require an order from a physician or another health care professional. Administration of medication is an example of a dependent intervention. This intervention requires specific nursing knowledge and responsibilities, but it is not within the realm of legal practise for nurses to prescribe medications.

The nurse is responsible for knowing the classification, normal dosage, pharmacological action, contraindications, adverse effects, and nursing implications of the drug. Dependent nursing interventions must be governed by appropriate knowledge and judgment.

Documenting the intervention

The implementation step also involves documentation and reporting. Data to be recorded include the client’s condition before the intervention, the specific intervention performed, the client’s response to the intervention, and client outcomes. Documentation provides valuable communication among health care team members to ensure continuity of care and evaluate progress toward expected outcomes. Written documentation also provides data necessary for reimbursement.

Verbal communication between nurses generally occurs at the change of shift, when caring responsibility changes. Nursing students must report relevant information to the nurse responsible for their clients when they leave the unit. Information that should be shared in the verbal report includes:

Completed activities and those not completed
Status of current relevant problems
Assessment changes or abnormalities
Results of treatments
Diagnostic tests scheduled or completed (and results)

Both written and verbal communication must be objective, descriptive, and complete. It must include observations, not opinions and be stated or written to show an accurate picture of the client’s condition. Communication of implementation activities is basic to client care and evaluation of progress toward goals.

Evaluation

Evaluation is done to assess the effectiveness of intervention and also to check whether the goal is met or not.

It is the fifth step in the nursing process, which determines whether client goals have been met, partially met, or not met. When a goal is met, the nurse decides whether nursing interventions should stop or continue for the status to be maintained. When a goal is partially met or not met, the nurse reassesses the situation. The reasons the goal is not met and modifications to the plan of care are determined by more data collection. Reasons that goals are not met or are only partially met include: