At which point in patient care would the nurse complete the evaluation step of the nursing process?

If there’s one thing you’ll need to understand while in nursing school, it’s the nursing process.

Since 1958, the systematic nursing process has guided nurses as they strive to provide patient-focused care. The system was developed by Ida Jean Orlando as a means of bringing critical thinking, problem-solving skills, and evidence-based practices (EBP) together with the knowledge and experience of the nurses to create a holistic, patient-first method of care. Since then, the system has become fundamental in nursing.

We’ll explore what the nursing process is and the five main components, or steps, that you will rely on to help you navigate the nursing field. Here’s what you need to know as you prepare for nursing school and your future.

What is the nursing process?

The nursing process provides nurses with a rational and systematic way of evaluating their patients and delivering holistic care in a patient-first paradigm.

This process is used to determine the health problems and needs of patients and to then identify the nursing interventions and processes that nurses can use to provide the best care for their patients. The process can also help nurses remain more organized as they determine the care they’ll provide.

Another purpose of the nursing process is to outline how nurses should act, which can protect them if there are any legal problems or challenges that arise as a result of the care a patient receives following the process.

The 5 components of the nursing process

There are five main parts of the nursing process that you’ll need to know as a nursing professional. They include:

Assessment

During the first step of the process, the registered nurse works to understand the patient’s condition and needs. They’ll do this by collecting a variety of data points, such as the patient’s health history, and using their critical thinking skills to collect observations.

The types of assessment data needed to complete this step include:

• Objective data: These include vital signs, patient weight, pulse, intake and output, etc.
• Objective observations: These include skin color, the ability of the patient to make eye contact, how easily the patient can get out of bed, and the sounds of the lungs.
• Patient data points: These subjective data points include the patient’s current physical feelings — such as feeling nauseated — and even emotional feelings, like anger or fear.
• Any other useful nonverbal data: This can include the patient’s overall appearance and body language.

The information in these different categories can all be collected from primary, secondary, and tertiary sources. The primary source would be the patient themselves. You would note client responses to your questions as primary source data. Secondary sources are people with whom the patient might confide — such as family or close friends — and tertiary sources might include textbooks or journals that provide an outside look at data points and data collection.

As a nurse, you’ll collect this information through physical examinations and by speaking with the patient and those with them. All of the data collected should be carefully recorded for later reference.

Diagnosis

During the diagnosis portion of the nursing process, a nurse brings together all the different data points they collected regarding their patient. They’ll use their experience, clinical judgment, and expertise to understand how the different points relate to each other so they can provide a nursing diagnosis. This diagnosis will articulate the patient’s needs and condition. Sometimes, patients might even require more than one diagnosis.

Nurses can consult the current list of nursing diagnoses offered by the North American Nursing Diagnosis Association (NANDA). These diagnoses follow Maslow’s Hierarchy of Needs, helping nurses understand how to help patients improve their overall health.

The diagnosis that the nurse lands on will then be used to guide them through the rest of the nursing process.

Planning

During the planning portion of the process, the nurse will now work to organize their thoughts and ideas surrounding the actions they’ll take to treat the patient. This planning step helps everyone involved in the nursing care know the course of action pursued, the goals the team has for that action, and what they expect to happen for the patient.

It’s important to note that planning is an ongoing portion of the nursing process. There is an initial planning stage, which is conducted immediately after evaluating the patient. Then, there is an ongoing planning stage that will regularly be conducted as the patient is cared for. The nurse will need to watch how the patient’s condition changes in response to their care, determine where to focus their attention on a given day, and set evolving goals based on the patient’s progress.

Finally, when the patient is ready to be discharged, the nurse will need to set a discharge plan of care. These plans articulate the support that the patient should have as they leave the clinical care setting and explain how the patient should coordinate care with other health care professionals.

The biggest thing is that the goals set by nurses should be SMART. A SMART goal is:

• Specific
• Measurable
• Attainable
• Realistic
• Time-oriented

Goals that follow these criteria can be easily evaluated, with nurses being able to tell how well they achieved their aim. Health professionals need to set both long-term goals and short-term goals.

Of course, all of this should be articulated in a nursing care plan, which explains the care needed and the risk factors the patient faces. A well-outlined plan can help ensure good communication between different nurses and members of the patient’s health care team.

Implementing

During the implementation stage, the nurse involved in patient care puts the plan into action. Based on the diagnosis and plan outlined in the above steps of the nursing process, the nurse will have predetermined medical nursing interventions that they’ll take to try to achieve their patient-related goals.

A part of this process also often involves informing the patient about the care they’re receiving (and why they’re receiving it) so they can do a better job of articulating whether the interventions work.

The interventions taken by nurses typically fall under a few different types of classifications:

• Interventions designed to target patient behavior: Behavioral interventions help adjust patient behavior for better health outcomes, such as helping with stress management or encouraging exercise.
• Interventions that help communities or families as a whole: These types of interventions benefit the patient as well as those around them, such as providing HIV education or helping family members better understand their loved one’s illness and how to care for them.
• Interventions to help patients in a clinical setting: Nurses follow interventions to help patients receive the best possible care and be safe while in the hospital. For example, they might regularly help patients adjust positions to avoid bed sores.
• Interventions to promote safety: Patients may also require help understanding how to use different medical devices. They also need to know how to move around independently.
• Interventions to help patients physically: Interventions to improve the patient’s physical health might include tasks like inserting an IV or helping the patient with physical hygiene. These also play a critical role in nursing care.

The Nursing Interventions Classification (NIC) publication helps create a standardized process for describing the problems that patients face. This can help nurses easily use the notes produced by other nurses, see what the nursing diagnosis is, and apply the recommended nursing interventions because everyone has a common vocabulary to work worth. This can aid communication between nurses and provide more consistent care for patients.

Evaluation

Finally, nurses will need to continually monitor and evaluate the success of the interventions they’re taking to make sure they’re effectively helping the patient.

During the evaluation phase, nurses should compare the patient outcomes they see with the desired outcomes they identified as goals during the planning portion of the nursing process.

This means regularly reassessing patients to determine if a new type of care is needed or if the plan needs to be adjusted.

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