Understanding the 5 Steps of the Nursing Process: A Comprehensive Guide with Examples: Free NCLEX – RN resource

Nursing Process

is a systematic, patient-centered approach used by nurses to ensure the delivery of effective and individualized care. It serves as a framework for critical thinking, problem-solving, and decision-making in nursing practice. The process consists of five essential steps. It is dynamic and continuous, allowing nurses to adapt their care based on the patient’s evolving needs. It is a cornerstone of nursing practice and ensures that care is evidence-based, organized, and patient-focused.

A: assessment

D: diagnosis

P: planning

I: intervention

E: evaluation

Assessment (What do you observe?)

Gathering and analyzing information about the patient’s physical, emotional, psychological, and social health through observations, interviews, physical exams, and diagnostic data.

Example of Nursing Assessment

A nurse is assessing a 65-year-old male patient admitted with shortness of breath and fatigue.

Subjective Data (What the patient says):

The patient reports, "I've been feeling very tired for the past week and get out of breath even when walking short distances. I also noticed some swelling in my ankles."

Objective Data (What the nurse observes and diagnostic data):

• Vital signs: Blood pressure 140/90 mmHg, pulse 96 bpm, respiratory rate 22 breaths/min, oxygen saturation 88% on room air.

• Physical examination: Bilateral pedal edema, crackles in the lungs upon auscultation, and pale skin.

• Diagnostic data: Chest X-ray reveals fluid in the lungs, and lab results show elevated BNP (brain natriuretic peptide) levels.

This systematic collection of subjective and objective data allows the nurse to form a complete picture of the patient's condition, guiding the next steps in the nursing process.

Diagnosis (What do you identify as the Problem?):

Identifying actual or potential health problems based on the assessment data. This involves creating nursing diagnoses that guide the care plan.

Example of Nursing Diagnosis:

Patient: A 65-year-old male presenting with shortness of breath, fatigue, and bilateral pedal edema.

Nursing Diagnosis:

• Impaired gas exchange is related to fluid accumulation in the lungs, as evidenced by shortness of breath, crackles on auscultation, oxygen saturation of 88% in room air, and chest X-ray findings.

• Activity Intolerance is related to decreased oxygenation and fatigue, as evidenced by the patient's reported inability to walk short distances without feeling breathless.

• Excess Fluid Volume related to heart failure as evidenced by bilateral pedal edema, elevated BNP levels, and fluid retention seen on the chest X-ray.

Each diagnosis is based on the assessment findings and provides a foundation for planning patient-specific care interventions.

Planning (What are your intended nursing interventions?):

This step involves developing specific, measurable, and achievable goals for the patient’s care and selecting interventions to address the identified problems.

Example of Nursing Planning:

Patient: A 65-year-old male with impaired gas exchange, activity intolerance, and excess fluid volume.

Goals (SMART format):

1.   Impaired Gas Exchange:

o   The patient will maintain oxygen saturation of at least 92% on supplemental oxygen within 24 hours.

o   The patient will demonstrate effective breathing techniques (e.g., pursed-lip breathing) during the current shift.

2.   Activity Intolerance:

o   The patient will report reduced shortness of breath after walking 20 feet with assistance within 48 hours.

o   The patient will increase activity tolerance by performing self-care activities with minimal assistance within 72 hours.

3.   Excess Fluid Volume:

o   The patient will show reduced pedal edema and a weight decrease of 2 pounds within 48 hours of initiating diuretic therapy.

o   The patient will verbalize understanding of fluid restriction and low-sodium diet by the time of discharge.

Implementation (Carrying out the plan of care):

Carrying out the planned interventions, such as administering medications, providing education, or performing procedures.

Example of Nursing Implementation:

Patient: A 65-year-old male with impaired gas exchange, activity intolerance, and excess fluid volume.

Interventions Implemented:

1.   Impaired Gas Exchange:

o   Administered oxygen therapy at 2 liters per minute via nasal cannula as prescribed.

o   Positioned the patient in a high Fowler’s position to facilitate lung expansion.

o   Encouraged the patient to perform pursed-lip breathing exercises every two hours.

o   Monitored oxygen saturation levels hourly and documented improvements.

2. Activity Intolerance:

o   Assisted the patient in walking 10 feet with a walker twice during the shift, allowing for rest periods as needed.

o   Provided emotional support to reduce anxiety related to activity limitations.

o   Monitored the patient’s heart rate, respiratory rate, and oxygen saturation before, during, and after activity.

2.   Excess Fluid Volume:

o   Administered prescribed diuretic (furosemide) at 40 mg IV and monitored urine output.

o   Measured daily weight and noted a 1-pound reduction from the previous day.

o   Educated the patient about reducing sodium intake and tracked food choices during meals.

o   Elevated the patient’s legs to reduce pedal edema and monitored swelling every 4 hours.

Documentation:

All interventions were documented in the patient’s chart, including the patient’s response to oxygen therapy, physical activity, and diuretic administration. Observations showed improved oxygen saturation (94%), reduced edema, and increased patient comfort during mobility.

This example illustrates carrying out the planned interventions and documenting the patient's response to care.

Evaluation (Was the goal achieved? What were the outcomes?):

Assessing the effectiveness of the interventions and determining whether the patient’s goals were met. If needed, the care plan is adjusted.

Example of Nursing Evaluation:

Patient: A 65-year-old male with impaired gas exchange, activity intolerance, and excess fluid volume.

Evaluation of Goals:

1.   Impaired Gas Exchange:

o   Goal: Maintain oxygen saturation of at least 92% on supplemental oxygen within 24 hours.

§  Outcome: Achieved. The patient’s oxygen saturation improved to 94% with 2 L/min via nasal cannula. The patient demonstrated proper pursed-lip breathing techniques and reported easier breathing.

2.   Activity Intolerance:

o   Goal: Report reduced shortness of breath after walking 20 feet with assistance within 48 hours.

§  Outcome: Partially Achieved. The patient was able to walk 15 feet with a walker and reported mild shortness of breath but showed improvement compared to the initial assessment. Monitoring and gradual activity increase will continue.

3.   Excess Fluid Volume:

o   Goal: Show reduced pedal edema and a weight decrease of 2 pounds within 48 hours of initiating diuretic therapy.

§  Outcome: Achieved. The patient’s weight decreased by 2.2 pounds, and pedal edema was visibly reduced. The patient verbalized understanding of fluid restrictions and low-sodium diet as part of ongoing management.

Reassessment and Plan Modification:

• The patient’s oxygen therapy will continue at 2 L/min with periodic reevaluation to determine if it can be weaned.

• Activity goals will be adjusted to focus on gradual increases in distance over the next 72 hours.

• Ongoing diuretic therapy and fluid/diet monitoring will remain in place to sustain improvements in fluid balance.

This evaluation demonstrates whether the goals were met, partially met, or unmet and outlines adjustments to the care plan as needed.