4723-4-07 Standards for applying the nursing process as a registered nurse.

(A) A registered nurse shall apply the nursing process in the practice of nursing as set forth in division (B) of section 4723.01 of the Revised Code and in the rules of the board. The steps of the nursing process are cyclical in nature so that the nurse's actions are directed by the client's changing status throughout the process. The nurse may collaborate with the client, family, significant others, and other members of the health care team in applying the steps of the nursing process. The following standards shall be used by a registered nurse, using critical thinking and clinical judgment, in applying the nursing process for each client under the registered nurse's care:

(1) Assessment:

The registered nurse shall, in an accurate and timely manner:

(a) Collect data. This includes:

(i) Collection of subjective and objective data from the client, family, significant others, or other members of the heath care team. The registered nurse may direct or delegate the performance of data collection; and

(ii) Documentation of the collected data.

(2) Analysis and reporting:

The registered nurse shall, in an accurate and timely manner:

(a) Identify, organize, and interpret relevant data;

(b) Establish, accept, or modify a nursing diagnosis to be used as a basis for nursing interventions; and

(c) Report collected data as necessary to other members of the health care team;

(3) Planning: The registered nurse shall, in an accurate and timely manner:

(a) Develop, maintain, or modify the nursing component of the plan of care, including establishing desired client outcomes and interventions; and

(b) Communicate the nursing component of the plan of care and all modifications of the plan to members of the health care team;

(4) Implementation:

The registered nurse shall, in an accurate and timely manner implement the current nursing plan of care which may include:

(a) Executing the current valid order or regimen by an individual who is authorized to practice in this state and is acting within the course of the individual's professional practice;

(b) Providing direct nursing care which is commensurate with the education, knowledge, skills, and abilities of the registered nurse;

(c) Assisting with care of the client;

(d) Delegating nursing tasks, including medication administration, only in accordance with Chapter 4723-13, 4723-23, 4723-26, or 4723-27 of the Administrative Code;

(5) Evaluation:

The registered nurse shall, in an accurate and timely manner:

(a) Evaluate, document, and report the client's:

(i) Response to nursing interventions; and

(ii) Progress towards expected outcomes of the plan of care; and

(b) Reassess the client's health status, revise the nursing diagnoses or the nursing component of the client's plan of care, and make changes in the nursing interventions as necessary.

(B) For purposes of this rule, standards for implementing the nursing process also apply to a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist.

Effective: 02/01/2009
R.C. 119.032 review dates: 10/16/2008 and 10/01/2013
Promulgated Under: 119.03
Statutory Authority: 4723.07
Rule Amplifies: 4723.01, 4723.28(B)(19), (27), (28), 4723.43
Prior Effective Dates: 12/1/1995, 4/1/1997, 4/1/1999, 2/1/2000, 2/1/2002, 2/1/2003, 2/1/2004