Nursing Process

 

Whether working as a nurse in long-term care or an acute hospital, to be successful, you must be familiar with the nursing process, and how each phase plays an important role in the care you provide.

 

The nursing process is a scientific method that is used by nurses to ensure the highest quality of care and has five phases:

  • Assessment

  • Diagnosis

  • Planning

  • Implementation

  • Evaluation

 

Assessment

Though technically LPN’s work under the supervision of an RN and “can’t assess”, as a nurse it is important you know how to gather information and assemble it in a way that can provide answers as to what is going on with the resident/patient. During the assessment phase, you will gather information about the status of the resident, including:

  • Spiritual

  • Psychological

  • Physiological

  • Sociological

 

Gathering the above information can be done through resident, family and staff interview, referencing the medical history and general observation, just to name a few. It is important not to overlook the importance of direct resident interaction during this part of the nursing process, as it can be invaluable and provide information that you would otherwise be unable to obtain.

 

Diagnosing

Yes, a physician is who needs to do the actual diagnosis of a condition, prescribe treatment, etc. However, as a nurse, you are trained to determine a preliminary diagnosis and base your recommendations to the physician, as well as the development of the care plan, on this preliminary diagnosis. Basically, you’re making an educated judgement about a health problem, or potential health problem, the resident is facing. This phase also includes whether a resident is at risk for developing further issues- such as the risk for constipation when a resident is taking opioids for pain management.

 

Planning

In this phase, a plan of action is developed. It is important that resident, nurse and physician agree on the diagnosis you have determined. At times, multiple diagnosis are in place and it will be part of the nurse’s role to help prioritize in which order to address each issue. Each issue identified should also have a goal that is measurable assigned.

 

Implementation

This is where the plan developed in the planning stage, is implemented. It can take hours, days, weeks or even months for a plan to be fully implemented. During this time, it is important the appropriate education is provided to the resident and his/her responsible parties, when appropriate.

 

Evaluation

At this time, the nurse evaluates the resident’s condition to see if the plan that was implemented had the desired outcome. Generally, there are three potential outcomes available during the evaluation phase: improvement, stabilization, decline (including death). Sometimes, you won’t get the opportunity to complete this phase, in the event the resident discharges. If it is determined that goals have not been met and intended outcomes have not occurred, you would start the nursing process over from the beginning, making sure to keep in communication with the physician.

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