Did You Know The 6 Steps In A Nursing Process?

Ida Jean Orlando formulated the Nursing Process to promote patient-centric good nursing practices

. The 4 original steps were eventually expanded to include Diagnosis, and Outcome Identification was hived off from planning, to make it a 6-step process.

*Assessment: The first step involves collecting in-depth data about the patient. You can use the following procedures to collect information: interviewing the patient as well as the family, doing a complete head to toe assessment, checking vital signs, getting details of the patient's medical history, asking questions, seeking the patient's comments and observing typical signs and symptoms.

*Diagnosis: The collected data now has to be analyzed, interpreted and validated by you. Here you must know about The North American Nursing Diagnosis Association (NANDA) which has several nursing diagnostics under its classification system. You will have to match the patient's problem with the NANDA diagnosis list, so you can address the particular problem. In most cases the problems will be more than one.

*Outcome Identification: Now you have to put together a set of goals. However, these goals have to be practical and measurable, and most importantly, should be outlined with participation from the patient and keeping in mind the particular coping capacity. But always bear in mind that whatever the goals, they have to be completely patient-focused.

*Planning: You must proceed to formulate a plan to achieve your goals. Based on the severity of the problem, you will assign it a priority, and outline various interventions to achieve the desired outcome of improving the health condition and / or of preventing further risks or illnesses.

*Implementation: This is the action stage where you will implement the plan, by communicating the patient's problems, diagnosis and goals with all members of the concerned team, and delegating specific responsibilities. The team will respond by making observations and preparing reports.

*Evaluation: After including the inputs of the team members, and taking into account the patient's response in the evaluation procedure, you can gauge the outcome with respect to the goals. The evaluation is not with the sole purpose of finding the success or failure of the plan, but to make the required adjustments. Thus this is not the final stage of the process, and can often lead you back to the assessment stage, to start the process all over again.

You will now understand that the process is not meant for your own nursing goals, but patient-oriented goals, with the purpose of personalizing the nursing practice and achieving the desired outcomes.

by: Susan Bean

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