Use a SMART Nursing Process
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Just like architects who makes elaborate and detailed blue prints before building any structure or work of art. Nurses' use Nursing Process - a patient centered, problem-solving approach, goal oriented method of caring, that enables the nurse to provide care in an organized scientific manner.
The objective of Nursing Process is to help patients alleviate, minimize, or prevent actual or potential health problems. Through effective communication between nurse and patients in any variety of settings this process is being carried out continually.
Summary of Five-Step Nursing Process
| Purpose | Key Actions |
|---|---|
| ASSESSMENT -To gather, verify, and communicate data about client so data base is established | Collect nursing health history.Perform physical examination.Collect laboratory data. |
| DIAGNOSIS -To identify health care needs of client; to formulate nursing diagnoses | Interpret data, including data validation and clustering.Formulate nursing diagnoses (see NANDA Approved Nursing Diagnosis) |
| PLANNING -To identify client goals; to determine priorities of care; to design nursing strategies to achieve expected outcomes of care; to determine outcome criteria- SMART – goal should be Specific, Measurable, Attainable and Realistically Time-bound. | Identify expected outcomes.Select nursing actions.Delegate actions.Consult.Write nursing care plan.Ex. To reduce fever within the baseline data of 35.5 by giving prn antipyretic medication and performing tepid sponge bath for 4 hrs. |
| IMPLEMENTATION -To complete nursing actions necessary for accomplishing plan | Reassess client.Review and modify existing care plan.Perform nursing actions. |
| EVALUATION -To determine extent to which expected outcomes have been achieved. Very important to DOCUMENT your action! This is very essential for legal matters. | Establish evaluation criteria. Compare client response to outcome criteria. Analyze reasons for result and conclusions. Modify care plan. |
Since I was a student and up to now that I am a Registered Nurse with years of experience I still follow this methodology. Achieving my desired goal gives me a feeling of accomplishment by the end of the day, week or semester.
I help out my patient through safe and competent care, how good it can be! Assisting my patients' support system through evidence-based health teachings. I gain and improved my self-esteem as a nurse and made my clinical instructor feel "effective" because of the progress.
Initially the steps are followed in sequence. After the process has begun, it becomes a continuous cycle. As you gain more experience and make use of it the more it sinks into your subconscious always ready for retrieval. Truly, using a SMART nursing process is a win-win strategy!
NURSING PROCESS
A. NURSING ASSESSMENT
Sources of Client Data
1. Patient itself
4. Laboratory and diagnostic tests
5. Health team members
B. NURSING DIAGNOSIS
Click the link below to see NANDA – Approved Nursing Diagnoses
Click here for Nursing Diagnosis- NANDA
C. NURSING PLANNING
1. Setting goals and priorities for patient
Criteria of expected outcomes should be SMART:
S - Specific and focused to the client – reflecting clients behaviorex. “the client will perform deep breathing twice a day”
M - Measurable – to quantify desired response objectively
ex. “the client’s systolic BP will be less than 160 mm Hg by 1/7.”
A - Attainable or perceivable – avoid statements “will be able to”
ex. “on the day of heart surgery, the client will demonstrate relief of anxiety by stating that all questions have been answered.”
R - Realistic – includes pts. Support system, emotional and physical condition,level of intelligence, health values, availability of workforce and equipments.
T - Time bound or time limited – so that nurse has a standard whether progress is being reasonable and to assist in setting priorities.
ex. To reduce fever within the baseline data of 35.5 by giving prn antipyretic medication and performing tepid sponge bath for 4 hrs.
2. Prioritizing nursing interventions to achieve desired goals
a)Independent – practices that require no supervision or direction from others
b)Interdependent – teamwork with other staff ex. Protocol
c)Dependent – instructions and orders of another professional
3. Documenting care plan
D. NURSING IMPLEMENTATION
- this is the ACTION oriented phase of nursing process
1. Reassess client
- Therapeutic communication - communicates properly and effectively is very essential. Like analysis, communication is an ongoing aspect of nursing process.
2. Review and revise care plan
- changes in diagnosis, interventions and evaluation to further indicate the desired level of wellness and indicate when the need has been resolved and nursing diagnosis is no loner relevant.
3. Organize
- being a patient advocate through precautionary measures
ex. Feeding a swallowing compromised client – nurse assist patient to a sitting upright position and crushing pills to swallow properly.
E. NURSING EVALUATION
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Thank You note for your contribution.
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