Nursing Process: An evolving procedure by which a person’s health status and needs are identified (assessment and diagnosis), plans are developed (planning), care is delivered (implementation), and outcomes are evaluated (evaluation) as the physical, social, and emotional problems of the person are resolved and/or new problems are identified. Nursing process consists of five components:
A. Components of the nursing process and expectations for the delivery of nursing care
1. Assessment and data collection
a) The purpose of the assessment component of the Nursing process as performed by the RN is to:
Determine the physical condition of the person by observation or report
Deliberately and systematically collect data about the person’s condition
and needs by observation or report
Determine the person’s current health status and the potential for change to
that status
Evaluate the person’s past and present coping pattern
Analyze data collected, identify problems, and recommend interventions
b) The assessment process shall include consideration of the following five factors:
Biophysical conditions (i.e., medical diagnoses and treatment plan)
Psychosocial environmental concerns
Self Care skills/deficits
Educational/ training needs of the person and those who provide support to
that person
Transition planning as appropriate
c) The LPN is permitted to support the assessment process through the collection of data, reporting of
pertinent observations, and suggestion of nursing intervention modifications based upon the
person’s response.
d) Nursing assessments support the planning process for individuals. For this reason, the responsible
RN or responsible covering RN shall complete an assessment of a person in their care according to
the following guidelines:
Prior to acceptance or within 2 working days of admission of the person to Community Living
Arrangements (CLA) or Campus based homes. RN/RN on Call must be immediately notified
when the person is admitted so orders can be reviewed and direction for care provided until
assessment is completed. Nurse may direct trained staff to complete a body check to document
presence of bruising or obvious skin alteration as well as vital signs upon admission.
Prior to admission or as identified by the individual’s planning process for services provided in
a Community Training Home (CTH), or Individual Supports/Own Home (formerly supported
living)
In conjunction with the discharge of the person from another care facility (i.e., hospital, LTC)
back to their home either within 24 hours prior to discharge or within 2 working days following
discharge. The RN/RN On Call must be called immediately upon the person’s return to the
facility orders can be reviewed and direction for care provided.
Nursing Standard 09.1 Nursing Process 3
Prior to the initial admission to a DDS Respite Center and as necessary to update information
prior to visits
At the frequency identified in regulation (i.e., ICF/MR, DDS Licensing) and to support the
planning and support process of the department (i.e., annually, semi-annually, and/or quarterly).
Whenever there is a change in the person’s needs or health status.
Prior to the planned discharge of a person from one home to another.
e) Generally, nursing assessments involve the visual inspection of the person being assessed. Some
assessments however, may be conducted as part of an identified communication/On-Call process in
which information is obtained from a caller according to the specified DDS RN On-Call procedure.
The RN using nursing judgment, collects all necessary data to determine the acuity of the situation,
and decides the action to be taken to ensure the health and safety of the person. The RN maintains
the option to visit the person’s home or to direct that the person have timely medical care at the
appropriate facility.
2. Nursing Diagnosis
The purpose of the Nursing Diagnosis as a component of the Nursing Process is to reflect the
nurse’s clinical judgment about the person’s response to actual or potential health conditions or
needs (i.e., A person in pain may demonstrate the potential for poor nutrition, anxiety, and/or
decreased mobility).
3. Planning
a) The purpose of the Planning component of the Nursing process is to develop the care plan that
specifies the goals and interventions that will be provided to the person to promote, maintain, or
restore their health, prevent illness and affect habilitation.
b) The RN shall develop the plan following collaboration with the person and others who support the
person. This plan shall be reflected in the individual’s plan of support.
c) The LPN can assist the RN in the development of the plan by providing data, contributing to the
identification of priorities, and contributing to the identification of realistic and measurable goals.
d) During the planning phase the RN shall consider the training requirements of the person,
family/guardian, and/or support staff, and the time frame that is necessary to implement this training.
e) The RN shall revise the plan when the needs of the person significantly change (i.e., new diagnoses,
new medications, changes in condition). This revision shall be reflected in nursing documentation.
f) For the purpose of completion of the Level of Need tool, and the development of the Individual Plan,
the health care plan shall be revised at a minimum, on an annual basis by the RN. A review of the plan
and the person’s response shall be completed by the nurse on a semi-annual, and/or quarterly basis as
required by regulation.
4. Implementation
a) The purpose of the Implementation component of the Nursing Process is for the RN and/or the LPN
under the direction of the RN, is to execute the elements of the identified plan.
b) The RN or LPN under the direction of the RN may delegate all or portions of the implementation of
the health plan to appropriately trained non-licensed personnel per the DDS Nursing Standard on
Delegation to Non-licensed personnel.
Nursing Standard 09.1 Nursing Process 4
c) The RN is responsible for the total plan which includes awareness of all aspects of the implementation
of the plan and the person’s response to it.
d) The RN is responsible to transfer information regarding the care plan when the person is transferred or
discharged to another facility.
e) The LPN is responsible to keep the RN advised about all aspects of the implementation of the plan,
the person’s response to the plan, and changes in prescribed treatments that may impact the plan.
5. Evaluation
a) The purpose of the Evaluation component of the Nursing Process is to determine the person’s
progress toward achievement of the identified goals and/or the revision of the care plan as new
problems are identified.
b) The RN’s evaluation of care can lead to changes in the elements of the plan and/or implementation of
those elements as the person’s status and needs change. This evaluation process is reflected in nursing
documentation such as focus nursing notes and in the completion of periodic Nursing/Health Care
reviews at the frequency identified in regulation.
c) The LPN supports the RN’s evaluation through communication of observations, data, and the person’s
response to treatment.
d) The RN is also supported in this component of the process through communication with others who
provide care, support, and/or information. (i.e., health care providers, family/guardian, staff).
B. Documentation of the Nursing Process
Utilization of the RN’s use of the components of the Nursing Process shall be evident in review of nursing
notes and other health related documentation. Refer to DDS Nursing Standard on Nursing
Documentation for current department requirements.
Credit: http://www.ct.gov/dds/lib/dds/health/ns_09_1_nursing_process.pdf