The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care.
Assessment
An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.
Diagnosis
The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse’s care plan.
Outcomes / Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.
Implementation
Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.
Evaluation
Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.
FAQs
To answer nursing exam questions, a very common test-taking strategy is using the steps of the nursing process (ADPIE) to help you prioritize. ADPIE is an acronym for these steps, which are assessment, diagnosis, planning, implementation and evaluation, and they follow this specific order.
What is the nursing process short answer? ›
The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective.
What is the nursing process quizlet? ›
The nursing process involves five steps: assessment, diagnosis, planning, implementation, and evaluation. Critical thinking and using the nursing process helps nurses to collect essential data, clearly express the needs of patients, and communicate those needs to the health care team.
Is there a trick to answering NCLEX questions? ›
Look for Opposite Answers
If two of the answer choices have opposites, like increased heart rate or decreased heart rate, one of the two choices is usually the correct answer. Correctly answering NCLEX-style questions requires familiarity with all the types of questions you may see on the exam, says Ross.
What words are bolded on NCLEX? ›
Does the NCLEX bold key words in items? Yes, the NCLEX bolds key words such as best, most, essential, first, priority, immediately, highest, initial, next, refute, increased, decreased and support. Does NCSBN use generic and trade names on items with medications? The NCLEX uses consistent language for every examinee.
What is the nursing process for dummies? ›
There are five main parts of the nursing process that you'll need to know as a nursing professional:
- Nursing Assessment. During the first step of the process, the registered nurse works to understand the patient's condition and needs. ...
- Nursing Diagnosis. ...
- Nursing Planning. ...
- Nursing Implementation. ...
- Nursing Evaluation.
The nursing process is a systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness. It has five steps; Assessment, Diagnosis, planning, implementation and evaluation [5].
Why use the nursing process? ›
It's an effective way for nurses to use their time more efficiently. It also promotes better communication practices between members of the healthcare team. The written resources generated from the nursing process increase the quality of care and provide evidence for nursing education and research.
What is the most critical step in the nursing process? ›
The assessment phase is a critical component of the nursing process. Information gathered in this phase is used to establish a foundation upon which all patient care moving forward is established.
Is nursing a lot of memorization? ›
While you'll definitely need to recall a wide range of information at the drop of a hat, memorization will only take you so far. Nurses must be able to put facts into action, applying critical thinking in fast-paced environments.
Example: A new patient is admitted to the unit. The nurse obtains the patient's blood pressure, heart rate, respiration rate, temperature, and oxygen saturation. The nurse performs a head-to-toe assessment and gauges the patient's pain level. The nurse documents this information.
What is a nursing process example? ›
Example: A new patient is admitted to the unit. The nurse obtains the patient's blood pressure, heart rate, respiration rate, temperature, and oxygen saturation. The nurse performs a head-to-toe assessment and gauges the patient's pain level. The nurse documents this information.
What is a process question example? ›
' Process questions require more thought and analysis and/or a sharing of opinion. Examples include, 'What skills can you bring to this organisation that the other applicants cannot? ' or 'What are the advantages and disadvantages of asking leading questions to children? '
What is the nursing process and problem solving? ›
The nursing process is a systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness. It has five steps; Assessment, Diagnosis, planning, implementation and evaluation [5].
