NURSIING PROCESS
Practice of nursing is caring which is directed by the way the nurses view the client, the client’s environment, health and the purpose of nursing. To nurses the nursing process provides a useful description of how nursing should be performed. As nurses remain in constant interaction with their clients, professional colleagues, medical and health care team members, they have the best opportunity to assess the patient’s needs and provide evidence based care.

The nursing process was first described by Hall in 1955 as a three step process. In 1967, Yura and Walsh added assessment to the three steps and described a four phase process. In the mid-1970s an addition of diagnostic phase resulted into a five step process. After 1980 the nursing process was added to the General Nursing Curriculm in India. In this unit you will learn the five phases of nursing process widely accepted and practiced by nurses all over the globe in various clinical settings. The steps of each process are explained.

CONCEPT OF NURSING PROCESS
Nursing is perceived to be both as science and an art. In Nursing we use integrated skills of biomedical, social and behavioural sciences for the care of the client. Therefore, nurses require knowledge and understanding of the principles of the disciplines from where it adopts and forms its base. The nursing is described in two ways: descriptive — the way the nursing actually happens and as normative — the way the nursing should be performed.
Traditionally nurses have focused on the needs namely comfort and sleep, nutrition, elimination, safety etc. to look after the patient as a whole. With changing times and also advances the design of nursing practice also changed. In the early 1970s nurses recognised the interaction between the various principles and the use of thinking logical process in planning nursing care.
In the development of nursing theories and various Models of Nursing. The basic concepts were Nursing, Person, Environment, and Health. The interrelationship between these elements established the foundation of professional nursing. The method by which the integrated knowledge is used to meet the needs of the client is given the name of Nursing Process. Nursing process evloved as a means to apply the various theories and models of nursing into nursing practice. The nursing practice is guided by holistic model that reflects the interrelationship of body-mind-spirit in order to maintaining, regaining, and promoting health.
In the year 1979, the American Nurses Association (ANA) defined nursing as “the diagnosis and treatment of human responses to actual or potential health problems.” The two words of nursing process are significant. Nursing and Process. Let us review what is Nursing and what is process to understand the combination of the two words.


Nursing
The description of nursing in all the definitions involves caring the clients during times of illness and assisting the client to achieve maximum health potential throughout the life cycle.

Process
Process is a series of rational thoughts, decisions and acts to achieve a goal. It implies a movement which has beginning, middle and an ending

1.2.1 Definition

Nursing Process (NP) is defined as a systematic, continuous and dynamic method of providing care to clients. It comprises series of sequential phases built upon the preceding step. Each phase logically leads to the next. As one step leads to the next step it results into ultimate achievement of mutually determined nursing outcomes/goals.

1.2.2 Phases of Nursing Process
The five phases of nursing process are:
Assessment that involves collection of information or details about the client obtained from different sources, e.g., through interview, physical examination using different methods and clinical examination.
Nursing diagnosis when information collected are analysed to draw conclusions or to identify the client’s problem(s).
Planning is development of strategies to alleviate client’s problem identified in nursing diagnosis through a series of steps.
Implementation is starting and completing the strategies planned with help of client, family members and health care team members.
Evaluation is assessment of strategies planned to alleviate the clients’ suffering or otherwise replan and revise the care.

1.2.3 Purposes/Uses
The nursing process provides a framework within which:
Nurses can identify client’s health status, and within which the individualised needs of the client, family and community can be met. Meeting the needs of the client can either be to achieve a level of optimal wellness or to contribute to his quality of life through maximising his resources.

It avoids unnecessary nursing actions. Although the phases are used concurrently, the process uses an organised approach and client’s problems are removed on the basis of the assessment.

It makes client and family feel important and participative in whole process of the care.
The nursing process is theoretically based and therefore uses the principles of biosciences, nursing and allied sciences i.e., behavioural, social sciences. It is a time saving device even though it takes time in the beginning.

1.2.4 Characteristics
The following characteristics describe the nature and vastness of the nursing process:

Dynamic and Cyclic
The dynamic nature involves continuous assessment and evaluation of changing client’s responses to nursing interventions so as to achieve the outcomes. Back and forth movement between the phases ensures quality care. Thus there is no absolute beginning or end

Client-centered
The plan of care is organised in terms of client problems rather than nursing goals. The nurse-client relationship is shaped around the needs of the client. Clients are encouraged to the extent that they are able to exercise control over their health and to make decisions about their case.

Planned and Goal-directed
Inverventions are considered according to the nursing diagnoses and are based on scientific principles rather than tradition. The nursing orders are chosen for the purpose of achieving client goals.

Universally Applicable
Nursing process can be used with clients of any age, with any medical diagnosis, and at any point on the wellness-illness continuum. It is useful in any setting (e.g. school, clinic, hospitals, homes, industries) and across specialities (e.g., hospice nursing, maternity nursing, pediatric nursing etc.)

Problem-oriented
Care plans are organised according to client’s problems. Interventions are carried out to eliminate the problems related to any aspect of an individual. When problems cannot be eliminated, the nurse relieves them to the degree possible, supports the client’s strengths in coping with the problem, and helps clients to understand and find meaning in their situation.

Cognitive Process
Nursing process involves the use of intellectual skills in making judgements, decisions and eliminating client’s problems. By way of critical thinking the nurse applies nursing knowledge systematically and logically to collect data that are meaningful and use the data to plan appropriate care.

1.2.5 Factors Affecting Nursing Process
Nurses knowledge, beliefs and technical skills are some factors that affect the phases of nursing process. How these factors affect the phase of nursing process is explained below.



Knowledge
Nursing process is the application of the nurses knowledge. Nurse has a knowledge base from both physical, biological and behavioural sciences. As part of her/his academic preparation nurse learns basic concepts of biochemistry, biophysics, microbiology, anatomy, physiology, psychology, sociology, nutrition. The knowledge of these sciences enables the nurse to recognise the problem more clearly and also determine how the client’s health is getting disturbed. By virtue of the knowledge of the nurse she/he is able to understand the interrelationship between client’s health, her/his health problem and her/his environment.
When a client has been brought in a critical condition the nurse can be flexible to select the right timing to collect health history as the nurse knows the demand of the situation. In such a situation she proceeds to the next phases of nursing process, coordinate with other departments to provide treatment strategies planned for the client.

Skills
Nurse uses technical and interpersonal skills to collect information about the client. The effectiveness of the nursing process depends on the intellectual (cognitive) skills of the nurse that she uses in creative and critical thinking, and decision making.

Technical skills are specific nursing skills performed to assess client’s health status e.g.
using thermometers, sphygmomanometer to measure blood pressure, performing procedures i.e., taking pulse, listening to the respiratory, heart, bowel sounds. Interpersonal skills help establish relationship between nurse, client, family and health care team. The nurse through use of communication skills determine client’s problem, help the client perceive actual or potential problem, prioritise problem, mutually sets goals to be achieved.

Beliefs
The nurse’s personal belief about nursing, health, the client as an individual, as a health care consumer forms the basis of nursing practice e.g. when a patient with AIDS with an attempt to commit suicide is admitted in the ward, the care of such a client gets affected by nurses personal beliefs that client with HIV infection should not be admitted in general ward. The nurse is also faced with a moral and ethical dilemma of providing care to such a client and his family members. If the client wishes to get discharge from hospital to stay at home with his family then the nurse’s belief that the goal of nursing care is to help the client to be in a state of comfort, free from infection, and so on. Therefore, the nurse teaches the family on prevention of infection and suggests referral to hospice centre. She also respects the client’s right to make decision about himself.