The nursing process, a cornerstone of modern healthcare, was initiated in 1958 by Ida Jean Orlando and continues to be the guiding framework for nursing care today. This systematic approach integrates critical thinking, patient-centered methodologies, goal-oriented strategies, evidence-based practices, and clinical intuition to deliver holistic and scientifically sound care. It serves as the bedrock for providing compassionate and high-quality patient care across diverse healthcare settings.
Understanding the Nursing Process
The nursing process is a structured, five-step method for delivering patient-centered care. These sequential steps are: Assessment, Diagnosis, Planning, Implementation, and Evaluation. Each stage is crucial and builds upon the previous one to ensure comprehensive and effective patient management.
Assessment: Gathering Patient Data
The initial step, assessment, is fundamental and relies heavily on critical thinking and meticulous data collection. This involves gathering both subjective and objective information. Subjective data comprises the patient’s or caregiver’s verbal descriptions of their health concerns and experiences. Objective data, on the other hand, consists of measurable and observable facts such as vital signs, fluid intake and output, and physical measurements.
Data sources can be diverse, including direct patient input, information from primary caregivers (family or friends), and electronic health records. The ability to critically analyze this collected data is paramount for nurses, highlighting the importance of concept-based learning in nursing education.
Diagnosis: Utilizing NANDA-I for Clinical Judgement
Formulating a nursing diagnosis is a pivotal step that utilizes clinical judgment to guide care planning and implementation. This is where the North American Nursing Diagnosis Association International (NANDA-I) plays a vital role. NANDA-I provides a standardized and regularly updated classification system of nursing diagnoses. According to NANDA-I, a nursing diagnosis is defined as a clinical judgment concerning a human response to actual or potential health conditions or life processes, for an individual, family, group, or community.
Nursing diagnoses are intrinsically linked to Maslow’s Hierarchy of Needs, a theory developed by Abraham Maslow in 1943. Maslow’s hierarchy prioritizes human needs, starting from basic physiological requirements to higher-level needs like self-esteem and self-actualization. In nursing, understanding this hierarchy is crucial as physiological and safety needs form the foundation of patient care. Addressing these fundamental needs is paramount before progressing to address higher-level psychological and social needs.
Maslow’s Hierarchy of Needs in Nursing
- Basic Physiological Needs: These are the most fundamental needs for survival and include necessities like nutrition (water and food), elimination, airway patency (suctioning when needed), breathing (oxygenation), circulation (monitoring pulse, cardiac function, blood pressure – the ABCs of resuscitation), sleep, sex, shelter, and exercise. In a care plan, a NANDA diagnosis here might be “Impaired Gas Exchange” related to pneumonia, as evidenced by decreased oxygen saturation.
- Safety and Security Needs: Once physiological needs are met, safety and security become primary. This includes injury prevention (using side rails, call lights, practicing hand hygiene, implementing isolation protocols, suicide and fall precautions, ensuring car seat and helmet use, and promoting seat belt safety). Creating a trusting and safe environment through therapeutic relationships and providing patient education on modifiable risk factors (like those for stroke or heart disease) are also crucial. A related NANDA diagnosis could be “Risk for Falls” related to muscle weakness and altered balance.
- Love and Belonging: This level focuses on social needs. Nursing interventions here involve fostering supportive relationships, implementing strategies to combat social isolation (addressing bullying), utilizing active listening and therapeutic communication techniques, and addressing needs related to sexual intimacy. An example NANDA diagnosis might be “Social Isolation” related to hospitalization and lack of visitors, as evidenced by patient statements of loneliness.
- Self-Esteem: Once patients feel a sense of belonging, esteem needs become important. This encompasses community acceptance, professional achievements, personal accomplishments, a sense of control or empowerment, and acceptance of one’s body image. A NANDA diagnosis could be “Disturbed Body Image” related to mastectomy, as evidenced by verbalization of negative feelings about body and avoidance of looking at incision site.
- Self-Actualization: At the pinnacle of Maslow’s hierarchy is self-actualization, representing the realization of one’s full potential. Nurses can support this through creating empowering environments, fostering spiritual growth, encouraging the ability to understand diverse perspectives, and helping patients reach their maximum potential. While less directly addressed with specific NANDA diagnoses in acute care, the overarching goal of holistic care supports self-actualization in the long term.
Planning: Setting Goals and Outcomes with Care Plans
The planning phase is where specific, measurable goals and outcomes are developed. These are directly linked to the nursing diagnoses and are formulated based on evidence-based practice guidelines. Patient-specific goals are crucial for achieving positive health outcomes. Nursing care plans are essential tools in this phase. They provide a structured roadmap for individualized care, tailored to each patient’s unique needs, considering their overall condition and any co-existing health issues.
Well-constructed care plans enhance communication among the healthcare team, improve documentation, facilitate reimbursement processes, and ensure continuity of care across the entire healthcare spectrum.
Effective goals are SMART:
- Specific: Clearly defined and focused.
- Measurable or Meaningful: Progress can be tracked and is relevant to the patient.
- Attainable or Action-Oriented: Realistic and achievable for the patient.
- Realistic or Results-Oriented: Feasible given the patient’s circumstances and focused on desired outcomes.
- Timely or Time-Oriented: Has a defined timeframe for achievement.
Implementation: Putting the Care Plan into Action
Implementation is the action phase where nursing interventions outlined in the care plan are carried out. This involves direct and indirect patient care actions, such as applying monitoring equipment (like a cardiac monitor), administering oxygen, medication administration, following standard treatment protocols, and adhering to evidence-based practice standards.
Evaluation: Assessing the Effectiveness of Interventions
Evaluation, the final step, is critical for ensuring positive patient outcomes. After implementing any nursing intervention, it is imperative to reassess or evaluate the patient’s response to determine if the desired outcome has been achieved. The frequency of reassessment depends on the patient’s condition. Based on new assessment data, the care plan may need to be modified to better meet the patient’s evolving needs.
Challenges in Nursing Process Implementation
Despite its established importance, the implementation of the nursing process in practice faces challenges. A 2011 study in Mekelle Zone hospitals revealed that nurses often lacked sufficient knowledge to fully implement the nursing process. Factors such as high nurse-to-patient ratios were also identified as significant barriers. Ninety percent of the study participants reported inadequate experience in applying the nursing process routinely. Resource shortages and heavy workloads further compounded these challenges, hindering consistent application of the nursing process in patient care delivery.
Clinical Significance in Modern Healthcare
In today’s complex and dynamic healthcare environment, the consistent use of the nursing process is more clinically significant than ever. Aging populations often present with multiple comorbidities, increasing the risk of overlooking critical health conditions.
As highlighted by Salmond and Echevarria, the healthcare landscape is constantly evolving, necessitating a transformation in traditional nursing roles. Nurses are uniquely positioned to drive change and significantly impact future patient care delivery models.
The Role of Critical Thinking and Concept-Based Curricula
Critical thinking skills are paramount in developing effective care plans, especially for patients with complex health issues. The shift towards concept-based curricula in nursing education is crucial in preparing nurses for this challenging healthcare arena.
Concept-based learning, as explored by Baron, is essential for moving away from traditional, content-heavy educational models. This approach fosters a stronger connection between nursing practice and education, bridging clinical knowledge with practical expertise. This integration is vital for new nurses transitioning into the workforce, enabling them to become valuable team members and leaders in the evolving healthcare system.
Learning should be the central focus, seamlessly integrated into current practice. It’s a dynamic and continuous process, requiring a collaborative learning environment between educators and students, preceptors and novices, mentors, and trainees.
Looking ahead, nurses must be adept problem-solvers, capable of navigating diverse and complex situations. This includes managing challenging nurse-patient ratios, prioritizing care with multifaceted approaches, working with limited resources, efficiently using electronic health records, and functioning effectively within interdisciplinary teams, demonstrating strong leadership.
Review Questions
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Maslow’s Hierarchy of Needs for Nursing Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN
References
1.Karttunen M, Sneck S, Jokelainen J, Elo S. Nurses’ self-assessments of adherence to guidelines on safe medication preparation and administration in long-term elderly care. Scand J Caring Sci. 2020 Mar;34(1):108-117. [PubMed: 31058362]
2.Younan L, Clinton M, Fares S, Samaha H. The translation and cultural adaptation validity of the Actual Scope of Practice Questionnaire. East Mediterr Health J. 2019 Apr 25;25(3):181-188. [PubMed: 31054228]
3.Epstein AS, Desai AV, Bernal C, Romano D, Wan PJ, Okpako M, Anderson K, Chow K, Kramer D, Calderon C, Klimek VV, Rawlins-Duell R, Reidy DL, Goldberg JI, Cruz E, Nelson JE. Giving Voice to Patient Values Throughout Cancer: A Novel Nurse-Led Intervention. J Pain Symptom Manage. 2019 Jul;58(1):72-79.e2. [PMC free article: PMC6849206] [PubMed: 31034869]
4.Shih CY, Huang CY, Huang ML, Chen CM, Lin CC, Tang FI. The association of sociodemographic factors and needs of haemodialysis patients according to Maslow’s hierarchy of needs. J Clin Nurs. 2019 Jan;28(1-2):270-278. [PubMed: 29777561]
5.Maslow K, Mezey M. Recognition of dementia in hospitalized older adults. Am J Nurs. 2008 Jan;108(1):40-9; quiz, 50. [PubMed: 18156858]
6.Raso A, Ligozzi L, Garrino L, Dimonte V. Nursing profession and nurses’ contribution to nursing education as seen through students’ eyes: A qualitative study. Nurs Forum. 2019 Jul;54(3):414-424. [PubMed: 31056754]
7.Hu J, Yang Y, Fallacaro MD, Wands B, Wright S, Zhou Y, Ruan H. Building an International Partnership to Develop Advanced Practice Nurses in Anesthesia Settings: Using a Theory-Driven Approach. J Transcult Nurs. 2019 Sep;30(5):521-529. [PubMed: 31060444]
8.Bird M, Tolan J, Carter N. Baccalaureate Nursing Students’ Perceptions of Learning in Mentored and Simulated Research Practica. J Nurs Educ. 2019 May 01;58(5):290-293. [PubMed: 31039263]
9.Salmond SW, Echevarria M, Allread V. Care Bundles: Increasing Consistency of Care. Orthop Nurs. 2017 Jan/Feb;36(1):45-48. [PubMed: 28107300]
10.Rigolosi R, Salmond S. The journey to independent nurse practitioner practice. J Am Assoc Nurse Pract. 2014 Dec;26(12):649-57. [PubMed: 24824941]
Disclosure: Tammy Toney-Butler declares no relevant financial relationships with ineligible companies.
Disclosure: Jennifer Thayer declares no relevant financial relationships with ineligible companies.
