The Nursing Process
Ida Jean Orlando developed her theory of deliberative nursing process in the late 1950s based on her observations of “good” and “bad” nursing. The patient is the central theme of her theory, which is one of the most effective and practical of all nursing theories.
Basically stated, the nurse's primary role in the nursing process is to find out what the patient's most immediate need is and to provide assistance. This is accomplished in five steps: assessment, diagnosis, planning, implementing, and evaluating. The nursing process is an ongoing cycle of these steps which you will repeat over and over with your patients.
Ms. Orlando's original theory included the nursing diagnosis step in assessment and therefore had only four steps. In practice over the past few decades, the process has expanded to five steps.Assessment
Whether you are aware of it, you adhere to the concepts of the nursing process everyday. You assess patients constantly. If you are an LPN, your assessment is limited to data collection only, but you most likely report your findings to an R.N. and help her to plan and deliver the care needed. Assessment involves two steps: collecting data as you proceed with your assessment and analyzing the data to 1) determine the patient's health status, his coping mechanisms, and ability to use them and 2) identify problems.Diagnosis
These problems translate into nursing diagnoses. You might formally choose from the NANDA list, or you may only informally incorporate them into your daily routines. As you know, nurses don't diagnose illnesses except in the case of NPs who have been specifically trained in this practice. Nurses make nursing diagnoses. Your diagnosis will provide the basis for selecting nursing interventions to help the patient to deal with his health status. Nursing diagnoses are based on clinical judgment about how the patient, his family, and possibly even his community, respond to his health status issues. These issues can be either actual health problems or potential health problems or any combination.Planning
The R.N. will develop a plan to prioritize the immediate needs of the patient that were discovered in the assessment and diagnosis phases. The LPN and nurse's aide, UAP, and other team members will be given directions about the plan. This plan may be a very formal written plan or may be made up on the fly utilizing your critical thinking skills. Your plan incorporates nursing interventions and goals to improve the patient's outcomes and the means to implement the plan.
The patient will always be the center of your plan when utilizing the nursing process. Plans and goals will be measurable and patient oriented such as, “the patient will demonstrate. …” Other measurable verbs include verbalize, state, ambulate, describe, identify, perform, display, apply, and avoid. Verbs which are too nonspecific should be avoided include learn, know, and understand. Your goals will not be nursing related or driven.
Following all delegation rules, the R.N. will provide direct care, delegate as appropriate, and supervise the team in implementing the plan and interventions to meet the patient's immediate needs. The team members need to report back to the R.N. any significant findings during this process. The R.N. needs to supervise the team and follow up to ensure that the delegated portions of the plan have been implemented.
Nursing interventions include treatments based on clinical judgments and medical knowledge and necessity that will enhance the patient's outcomes. These interventions may be initiated by the nurse, the physician, or other health care team member.Evaluation
Based on findings reported from team members including herself and the patient, the R.N. will evaluate the effectiveness of the plan. She will make revisions as needed and discuss them with team members, including consulting with the physician for new orders. The R.N. will also evaluate for new requirements and begin the process again.
The evaluation process is a reassessment. It includes collection of subjective data, which is what the patient or team members tell you. You will also include your own objective data, which is what your senses tell you — what you see, smell, hear, and feel. The subjective data are the symptoms and the objective data are the signs.
Even if you don't actually write out a formal care plan for each patient, you are still using the nursing process to direct your care. The care you give and delegate and the documentation of that care, reflects the five stages of the nursing process: assessment, diagnosis, planning, implementation, and evaluation.
The nursing process is one of the most misunderstood concepts. Most students struggle with it and for some, it takes a long time before it becomes clear. As you deliver your care each day, think about how you are applying this process to your patients.