The nursing process

As a nursing assistant, you will be heavily involved in client care and the nursing process. The best practice is to focus on the client’s needs which is why it is called client-centered care.

Clients are considered active participants in their care. They are informed, involved in all decisions, and are encouraged to ask questions.

Their preferences and values should always be respected.The nursing process is a systematic guide nurses use to provide the best care for their clients.

It consists of five steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation. In the first step, Assessment, the nurse collects and analyzes information about the client.

The nursing assistants contribute to this step with the observations they made during client care. There are two types of information: subjective and objective.

Subjective information is usually collected from the client. So, Subjective information is what clients Say, like, “I’ve been feeling more tired lately,” or, “The pain in my leg is really bad.

Like an 8 out of 10.” Objective information is measurable, like the client’s height, weight, vital signs, and so on. Keep in mind that the pain scale is a subjective measure because it’s something the client reports and not something you can objectively measure or observe.

In the next step, Diagnosis, a nursing diagnosis is made based on the collected information and the client’s problem. The third step, Planning, is about setting goals for the client and planning nursing interventions to reach these goals.

A client care conference is organized so you and other members of the healthcare team can share information about the client.

The fourth step, Implementation, involves performing planned interventions. As a nursing assistant, the nurse will assign you to perform tasks related to these interventions, like turning a client over in bed to prevent pressure ulcers or helping them with bathing.

In the final step, Evaluation, the effectiveness of the nursing care plan is measured and evaluated. This is another step where the information and observations you recorded come in handy.

It is your responsibility to inform the nurse about the client’s progress. The nurse will then determine if the client’s progress is satisfactory and if the nursing care plan needs to be changed.

One important thing to keep in mind is that a nursing diagnosis is not the same as a medical diagnosis. A medical diagnosis is made by a doctor or practitioner, and it’s focused on the disorder or condition; while the nursing diagnosis is made by a nurse and is focused on the client’s response to that disorder or condition.

For example, mitral valve stenosis, which is the narrowing of the mitral valve in the heart, is a medical diagnosis. For the same client, a nursing diagnosis could be activity intolerance related to the mitral valve stenosis.Now, the nursing process is used to develop the nursing care plan which is a formal guide for the client’s care.

The care plan is used as a communication device for the healthcare team. Nursing diagnosis, goals, interventions and client information are recorded in the nursing care plan and are part of the client’s permanent medical record.When a nurse wants to assign you tasks, they will often use an assignment worksheet.

It contains information about the client, like their room number, name, ID number, and so on; and tasks need to be done on behalf of the client.

Always ask the nurse about any assignments you don’t fully understand or if you have any questions.All right, as a quick recap… As a nursing assistant, you will be heavily involved in the nursing process which is used to develop a nursing care plan.

During the Assessment step, you should report and record your observations about the client. This information is used to make a nursing Diagnosis.

In the third step, Planning, you can share information about the client to assist in planning interventions. Implementation is the fourth step, during which a nurse will carry out planned interventions while you perform tasks related to these interventions.

After reporting and documenting your interventions, the provided information will be helpful in the final step called Evaluation which is used to determine if the client is reaching their goal or not.