The nursing process is the plan for the care of the patient based on individual needs of the client.
The components of nursing process are:
1. Assessment: This is the first step and it mainly includes data collection and critical thinking from the care giver.
The assessment includes Objective data and Subjective data.
Objective data is the information from the patient or family Eg: intensity of pain, type of pain, expression of fear
Subjective data is the information elicited by the caregiver and it is measurable data. Eg: Temperature, Heart rate, Blood pressure
2. Nursing Diagnosis: The nurse defines the nursing diagnosis based on the assessment and the nursing diagnosis is base on the Maslow's hierarchy of needs. NANDA defined nursing diagnoses are updated periodically.
Eg: Ineffective breathing pattern ; Risk for infection
Planning: This is the third step in the nursing process and here based on the diagnosis , the outcome of care is planned. There are time bound, specific, measurable, attainable and realistic goals for the care .
Eg: The client maintains an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and absence of dyspnea.
Patient remains free of infection, as evidenced by normal vital signs and absence of signs and symptoms of infection.
4. Implementation : This step in the nursing process involves the activity phase, where the planned care is carried out in reality. Here the nurse provides the nursing care as planned .
Eg: Administration of medicine; Administration of Oxygen ; Assist with ADL.
5. Evaluation: This is the last step in the nursing process where the nurse must reassess or evaluate to ensure the desired outcome has been met.
Eg: The client resumes normal breathing pattern as evidenced by respiratory rate, oxygen saturation and blood gas values.
The client remains free of infection with normal vital signs and no signs of infection