Utilizing The Nursing Process As A USRN

The Nursing Process is both a scientific and clinical reasoning guideline for nurses to utilize when approaching client care. To utilize the Nursing Process, the nurse navigates through each of the five steps in a cyclical manner, which includes assessment, nursing diagnosis, outcome planning, implementation, and evaluation. The Nursing Process is goal oriented and used as a problem solving method to approach nursing care. Each of the five steps directly impacts another and must be completed in order. In clinical practice or when approaching NCLEX questions, the assessment is always the first step in the Nursing Process that must be completed. Without the gathering of data and collecting information, the nurse would not be able to analyze and interpret it, which is needed to develop an accurate nursing diagnosis. 

If an NCLEX taker is approaching a question where the assessment data is provided, the test-taker would simply move to step two of the nursing process, nursing diagnosis. If no assessment date is provided in the NCLEX question, the nurse must first gather the required data and information, and would likely choose an answer related to assessment.

The Five Steps Of The Nursing Process

Step One: Assessment

The assessment involves gathering data and collecting information. This may include completing vital signs, a head-to-toe assessment, lab tests, a patient questionnaire, etc. Ongoing assessments may take place such as when the client's condition changes and new data is required. Data and information can be historical such as with a previous experiences and surgeries or current such as with a recent set of lab work; subjective such as with a client's description of symptoms experienced during anxiety attack or objective such as with the client's vital signs during an anxiety attack; primary such as with data gathered directly from the client or secondary such as with data gathered from sources other than the client; or involve physical, psychological, emotional, or spiritual components.

Step Two: Nursing Diagnosis

Developing a nursing diagnosis involves taking the information gathered from the assessment, analyzing and interpreting it, and identifying both the problems and strengths of the client. The nurse will use critical thinking, their knowledge and expertise, as well as the data and information gathered in the assessment step to determine a client's health related risk factors, active problems, and their strengths and areas of growth. It is imperative that a nursing diagnosis remains within the defined scope of practice of the nurse and is not a medical diagnosis. A nursing diagnosis should be either problem-focused (e.g. impaired gas exchange), a risk (e.g. risk for imbalanced fluid volume), health promotion (e.g. sedentary lifestyle), or a syndrome (e.g. ineffective tissue peripheral perfusion). Common descriptive words used in a nursing diagnosis may include acute, chronic, altered, ineffective, imbalanced, compromised, increased, or decreased.

Step Three: Outcome Planning

The outcome planning step involves developing nursing goals to achieve desired outcomes. Nursing interventions are planned in this step. Planning should be completed with the client, family (if appropriate), nurse, and interdisciplinary team. Planning should be specific and clearly identify the needs of the client so that it can be evaluated for its effectiveness. Planning should remain current and accurate, and may change as new information and data is gathered or client-focused goals change. Expected outcomes and client goals should be identified and can be created for any stage in the clients care, from admission to discharge. Planning of care should be prioritized using established frameworks such as the Maslow's Hierarchy of Needs and the ABCs. Outcomes should be utilized using the SMART goal approach which is (s)pecific, (m)easured, (a)achievable), (r)elevant, and (t)imed.

Step Four: Implementation

Next, the nurse implements the planned nursing interventions. The implementation step will continue to require prioritization and critical thinking. The nurse should only implement care that is within their scope of practice. Some interventions may be independent, such as with assisting a client to the commode, while others are dependent, such as those requiring a practitioners order (e.g. an order to administer IV Vancomycinl)

Step Five: Evaluation

The nurse evaluates the effectiveness and clinical status of the client by gathering and comparing the pre- and post-intervention data and information. This information can be used to determine if the expected outcome was met, partially met, or not met at all. Modifications may need to be made earlier in the nursing process if goals were only partially met or not met at all. For example, if the client centered goal was to achieve a pain score of 2/10 and the client reports a pain score of 4/10 following the implementation of the nursing intervention(s), the nurse may need to modify parts of the nursing process to achieve the client set goal.

Sources:

The Ultimate Guide To Nursing Diagnosis In 2022 (2022). Nursing.org. Retrieved June 2022. https://nurse.org/resources/nursing-diagnosis-guide/

Expert Report On The Responsibility Of Nursing. Maria Müller-Staub. Swiss Nursing Science Association. Retrieved June 2022. https://www.researchgate.net/figure/The-Nursing-Process_fig1_283091709