The nursing process—the vital core of practice for the registered nurse to give holistic, patient-focused care—unites different types of nurses who operate in diverse fields.
The first step in providing nursing care is for an RN to gather and analyze data about a client in a structured, dynamic way. In addition to physiological information, assessments also take into account psychological, social, spiritual, financial, and lifestyle aspects. For instance, a nurse’s evaluation of a hospitalized patient experiencing pain takes into account the patient’s response as well as the physical causes and symptoms of the pain, such as an inability to get out of bed, a refusal to eat, a withdrawal from family members, anger toward the hospital staff, fear, or a request for additional pain medication.
The nurse’s clinical assessment of the client’s reaction to current or potential health issues or needs constitutes the nursing diagnosis. The diagnosis shows that the patient is not only in pain, but that the pain has also contributed to other issues like anxiety, poor nutrition, and family strife, or that it may in the future contribute to complications. For instance, respiratory infection poses a risk to a patient who is immobilized. The nurse’s care plan is built around the diagnosis.
Results / Planning
The nurse establishes both short- and long-term goals for this patient based on the assessment and diagnosis. These goals may include moving from bed to chair at least three times per day, maintaining adequate nutrition by eating more frequently and in smaller portions, resolving conflict through counseling, or managing pain with the help of appropriate medication. The patient’s care plan includes assessment information, a diagnosis, and goals so that nurses and other medical personnel involved in the patient’s care can access them.
In order to ensure continuity of care for the patient during hospitalization and in the lead-up to discharge, nursing care is provided in accordance with the care plan. The patient’s record contains information about care.
The care plan must be continuously assessed for both the patient’s condition and the efficacy of the nursing care.