Steps of Nursing Process Assessment

The main task of a nurse is to assess the patient’s state correctly and offer optimal treatment. For this purpose, a nurse performs mandatory steps called the nursing process, and most often, they form a cycle rather than a linear sequence (Yoost & Crawford, 2019). These steps are assessment, diagnosis, planning, implementation, and evaluation. The first step in accepting a new patient is to assess his or her health conditions. This step includes interviewing the patient, reviewing the medical history, determining symptoms, and laboratory testing (Yoost & Crawford, 2019). For instance, a nurse must assess the emotional state of the patient with a first-time diagnosis. At the same time, the study of medical history is more significant for patients with chronic diseases. The next step is the nursing diagnosis, which means identifying the patient’s primary medical problems and needs. For example, a nurse can diagnose anxiety due to the disease’s detection by assessing the symptoms. The diagnosis can also relate directly to the problem; for example, the possibility of pressure ulcers due to limited mobility.

Further, a nurse proceeds to the planning step, which takes into account the needs of the patient and sets short-term and long-term goals. The short-term goal can be to reduce pain associated with a knee injury, while the long-term goal is to help a patient walk again. The next step is implementing the treatment, which includes monitoring compliance with a physician’s prescriptions, independent or collaborative care of the nurse and other specialists, and documentation of the treatment progress (Yoost & Crawford, 2019). For instance, a nurse needs to bring medicines to patients who cannot move by themselves, as well as monitor their nutrition, hygiene, and emotional state. For a patient undergoing physical rehabilitation, a nurse must also bring medication, accompany him or her to procedures, and assess treatment progress. The next step is evaluating a patient’s health, the effectiveness of treatment, and its progress. This step involves deciding whether to continue treatment and making recommendations, such as dieting and exercising, or prolonging observation and medication. Thus, a nurse provides treatment to patients and, under favorable circumstances, improves their health by completing all these steps.

Reference

Yoost, B., & Crawford, L. (2019). Fundamentals of nursing e-book: Active learning for collaborative practice. Elsevier Health Sciences.