STANDARDS FOR APPLYING THE NURSING PROCESS FOR RNsĀ
[This section covers subsections (A) and (B) of the OAC 4723-4-07, Standards for applying the nursing process as a registered nurse.]
A registered nurse must apply the nursing process in the practice of nursing as set forth in division (B) of section 4723.01 of the ORC and in the rules of the board. Nurses give care to patients using a cyclic series of steps called the nursing process. With critical thinking and clinical judgment, RNs assess, analyze/report, plan, implement, and evaluate the changing status of patients. They apply the nursing process in various practice settings and collaborate with patients, family, significant others, and members of the healthcare team according to the following standards.
The standards for implementing the nursing process also apply to a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist.
Assessment
Assessment involves the accurate and timely collection of both subjective and objective data about a patient’s condition from the patient, family members, significant others, and members of the healthcare team. The RN may direct or delegate the gathering of data but must document and report it, as appropriate, to other members of the healthcare team.
Analysis and Reporting
In an accurate and timely manner, RNs identify, organize, assimilate, and interpret relevant data. They establish, accept, or modify a nursing diagnosis, which is used as a basis for nursing interventions, and report the patient’s health status and nursing diagnosis as needed to other members of the healthcare team.
Planning
In an accurate and timely way, RNs develop, establish, maintain, or modify the nursing care plan with current nursing science, including the nursing diagnosis, desired patient outcomes or goals, and nursing interventions. They communicate the plan of care and all modifications to members of the healthcare team.
Implementation
In an accurate and timely way, RNs implement the nursing care plan. They execute the nursing regimen; implement current valid orders or directions by authorized practitioners; and provide nursing care commensurate with their education, knowledge, skills, and abilities. They assist and collaborate with other healthcare providers in the care of the patient and delegate nursing tasks, including medication administration, only in accordance with applicable rules and laws (see also “Delegation Guidelines” earlier in this course).
Evaluation
In an accurate and timely way, RNs evaluate, document, and report patient responses to nursing interventions and progress toward expected outcomes to appropriate members of the healthcare team. They then reassess the patient’s health status, establishing or modifying any aspect of the nursing plan.