The Nursing Process
The nursing process is a systematic way a nurse decides how to treat the patient’s
responses to health and illness. There are five steps in the nursing process:1.Assessment
2.Diagnosis
3.Planning
4.Intervention/Implementation
5.EvaluationAssessmentis data collection. During the assessment step, the nurse is gather-
ing subjective and objective data from the patient that will later be used to arrive
at a nursing diagnosis. Subjective data is information that is reported by the patient
such as, “I’m feeling warm.” Objective data is information that can be measured
or observed, such as the patient’s temperature or the color of the patient’s skin.
Diagnosisis the patient’s problem, which is determined by analyzing data
collected during the patient’s assessment. The data could lead the nurse to deter-
mine that the patient has more than one problem. This diagnosis is referred to as
a nursing diagnosis. A nursing diagnosis is different from a medical diagnosis.
For example, a nurse might diagnose an alteration in mobility in a patient who
has had a stroke. A physician or advanced nurse practitioner determines the med-
ical diagnosis, which is cerebral vascular accident (CVA). The nurse might also
determine this patient has a potential for alteration in nutrition because he or she
is having difficulty swallowing because of the stroke.
Theplanis how the nurse proposes to treat the nursing diagnosis. The plan
takes the form of a care plan that itemizes the patient’s nursing diagnosis. Each
nursing diagnosis will have an expected outcome or goal. The care plan contains
at least one nursing intervention for each nursing diagnosis, the expected out-
come for each intervention, and how the nurse will evaluate the outcome. For
example, the final outcome goal for an alteration in mobility might be to have
the patient get out of bed and ambulate without assistance. However, the inter-
ventions will begin with getting the patient out of bed and to the chair or assist-
ing the patient to walk short distances each day.
Theinterventionis executing the plan. For example, the nurse will assist the
patient to the chair the first time and might delegate the task to a nursing assis-
tant thereafter if the patient does not have any problems.
The evaluationstep of the nursing process determines if the intervention
worked. For example, the nurse evaluates the patient’s response to getting out of(^42) CHAPTER 3 Pharmacology and the Nursing Process