This is particularly important if red flags are identified in the evaluation step that may suggest the onset of a post-operative or other complication. Overall, the nursing process provides a valuable framework that engages critical thinking, continual assessment, and reassessment of the patient’s status. Evaluation is the final step in the nursing process, yet it directs the nurse back to the first step of assessment. To complete the evaluation, the nurse determines whether data such as the pain score, vital signs, and other parameters are within defined limits. In the fifth step, the nurse evaluates how effective the nursing interventions were in addressing the nursing diagnosis. This includes implementing the plan and documenting the care provided. The fourth step is intervention: to act upon the plan. Involvement of the patient may also include providing health teaching on strategies to prevent and manage post-operative pain. The nurse would involve the patient and/or family, as appropriate, in selecting the intervention(s), to ensure that consent has been obtained. With a diagnosis of pain, the nurse can establish a plan to use pharmacological and non-pharmacological interventions, as appropriate.
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In the third step, the nurse plans how to address the problem identified. Establishing a nursing diagnosis then leads to the third step of the nursing process: the planning phase. For example, in the patient who has undergone a surgery to repair a fractured hip, the pain may be localized, acute, and post-operative in nature, versus stemming from complications such as compartment syndrome, deep-vein thrombosis, or chronic pain syndrome. Part of the assessment is to identify the type and source of pain. For example, if the assessment identifies the presence of tachycardia, tachypnea, a pain score of 8/10, and a reluctance to mobilize, the nurse may diagnose the presence of pain. Step 2-Diagnosisīased on the assessment, the nurse will next identify a nursing diagnosis. Some of the components of a post-operative assessment include obtaining vital signs, pain score, assessing breath sounds, fluid intake and output, level of consciousness, the surgical site, and more (see List 1 below). This can be viewed as the most important step of the nursing process, as it determines the direction of care by judging how the patient is responding to and compensating for a surgical event, anesthesia, and increased physiologic demands. In the first step of the nursing process, the nurse gathers key information in completing a comprehensive patient assessment. The sequence must be followed from start to finish to ensure that the needs of the patient are addressed (Morris, 2006).
These five steps are used cyclically and repeatedly during patient care. The steps of the nursing process include assessment, nursing diagnosis, planning, intervention, and evaluation. It is a tool for both students and nurses to help ensure a consistent and strategic approach to patient care. The nursing process is a stepped approach to assess and care for patients. Nursing students are introduced to the nursing process during academic preparation. This article outlines how the nursing process must be embedded in patient care to ensure optimal outcomes for acute and complex patients. The 79-year-old female who has just had a hip fracture repair is not just “a hip” patient, but may also be an individual with diabetes, osteoporosis, hypertension, alcohol use disorder, asthma, obstructive sleep apnea, or early-stage dementia. For the nurse who works on an acute medical-surgical unit, it can be challenging to address the demands of post-operative assessment and care, as well as common medical challenges such as advanced age, obesity, and co-morbid disease. The acuity of patient care in the hospital setting has grown significantly over the last 10 years. The nursing process is an important strategy for both students and nurses to use in ensuring patient needs are met.Using the nursing process ensures a consistent approach. Acute and complex patients require continuous monitoring.
The five steps of the nursing process provide an invaluable tool in ensuring optimal patient care.
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