The Nursing Process

"Never try to solve all the problems at once — make them line up for you one-by-one."

— Richard Sloma

One of the most common complaints you hear from nursing students centers around the concept of care planning.  That dreaded task where a student/nurse looks at the patient, tries to figure out what is wrong with him/her and makes a plan to address the issue.  Students tend to think it's a waste of time--they will tell you that "real" nurses don't ever care plan and it teaches them nothing.  Students say a lot of things that don't make sense and this is one of them.  Care planning is just problem solving in disguise--a systematic approach to complex issues allowing time and energy to be well spent and productive.

For some reason, when we frame the process in nursing language it confuses people--so I like to take tangible, "real life" examples and turn them into nursing care plans. 

Step one:  assessment.  What is wrong?  You start by listing everything abnormal and then categorize and prioritize them.  Example:  My house is messy, I'm tired, I'm broke, I'm cranky, I have homework to do.  Let's pretend my biggest concern is having a messy house.  What specifically is messy?  Here's where you need to get down to the nitty gritty--messy isn't descriptive or objective, describe what is actually out of order.  There are toys on the floor, dirty laundry in piles, clean laundry (unfolded) on the table, trash flowing out of the can, etc. 

Step two:  diagnosis.  Analyze the data to determine what your problem is and why you have it.  The crucial thing here is determining your actual problem, in nursing we have a list to choose from, and identifying its root cause.  It does you no good to name the problem if you then mis-identify the cause.  Example:  my baby is crying.  If I decide to change the baby's diaper but that's not why he's crying, I won't ever solve or improve upon my problem.  Going back to my messy house--let's name our problem impaired kitchen integrity.  Now I have to figure out why--because I have too much stuff, messy kids, I don't put things away when I'm finished with them, too little space?  This is where people really stumble at problem solving--they know what they don't like and they know what they want as an end result but they fail to identify the root cause of the problem.  No organization system is going to keep your closet clean if the real problem is that you don't put things back where they belong.  No amount of income will meet your needs if your real problem is that you spend all your money on luxuries.  Once I determine my cause, my "related to" in nursing terms, I'm ready to plan.

Step three:  planning.  This is a two step process beginning with goal setting.  The easiest way to start is reverse your diagnosis.  If my diagnosis is pain, my goal is no pain.  My diagnosis of "impaired kitchen integrity" so my goal is improved kitchen integrity.  A goal has to be three things:  specific/measureable, realistic, and have a time frame.  I meet specific/measureable by adding outcome indicators--in real language, things that tell me how I know I have improved kitchen integrity; for instance, no dishes left in the sink, table clear of clothing, and floor swept and mopped.  Make sure it's reasonable to achieve and set a time--at the end of each day perhaps.  Part two is the writing of nursing interventions, activities to be done by the nurse to improve or eradicate the root cause of our problem.  Mega important point here--your interventions fix your cause, with the cause fixed the problem improves/disappears.  In this case we might identify the reasons for the clutter on the table, establish a schedule for dishwashing, determine an alternative space for laundry, and teach time saving techniques. 

Step four:  implementation.  This is the easy part, you do what you said you were going to do.

Step five:  evaluation.  The most overlooked of all steps in the process, once you have completed your implementation, enacted your plan, you have to go back and see if it worked.  Did you meet your goal?  If so, great--keep doing what works.  If not, figure out what worked, and what didn't, and modify the plan.  This might include a goal revision if you determine your goal was too far reaching, or maybe you need a little more time to meet it.  The revision might be to change or add interventions if you think you need more or different activities.  It might even require an adjustment to the original diagnosis--which sometimes happens when you realize that you addressed what you thought was the cause and the problem still persists.  As in, "I changed that baby and he's still crying--now what?"

Once you know the steps, not only does care planning for your patients become much easier, you also have a skill you can apply to all areas of your life.  Happy problem solving!