The nursing process is a systematic and dynamic approach that guides professional nursing practice globally. This framework provides an organized method for delivering individualized and holistic patient care. By employing this structured method, nurses apply scientific reasoning and evidence-based practice to their decision-making. The process is foundational to professional accountability, providing a documented record of actions taken to improve patient health outcomes.
Assessment: Gathering Patient Data
The process begins with Assessment, which involves the comprehensive collection of patient-related health data. Data is typically categorized as either subjective or objective, providing a complete picture of the patient’s current condition. Subjective data consists of information relayed by the patient or their family, such as reported symptoms, feelings, perceptions, or pain levels (e.g., “I feel nauseous”). Conversely, objective data is measurable and observable, collected through physical examination, observation, and diagnostic testing. Examples include a blood pressure reading of 140/90 mmHg, a temperature of 101°F, or observing a patient limping.
Nursing Diagnosis: Identifying Patient Needs
Following data collection, the nurse moves into the Nursing Diagnosis phase, which requires analyzing and synthesizing the gathered assessment data. A nursing diagnosis is a clinical judgment about an individual’s responses to actual or potential health problems. This judgment identifies specific patient-centered problems that nurses are licensed to treat independently, such as “Impaired Physical Mobility” based on objective data like a limping gait. It is important to differentiate a nursing diagnosis from a medical diagnosis. A medical diagnosis, such as “Hip Fracture,” identifies a specific disease treated by a physician. In contrast, a nursing diagnosis, like “Risk for Fall” or “Acute Pain,” focuses on the patient’s holistic response to that condition. Nurses address these responses through interventions within their scope of practice, such as implementing fall precautions. Standardized language from organizations like NANDA International is used to formulate these diagnoses, promoting clear communication.
Planning: Setting Goals and Interventions
The Planning phase transforms identified patient needs into a blueprint for care. The nurse first prioritizes the nursing diagnoses, focusing on immediate safety or physiological needs. The next step involves establishing measurable, achievable, relevant, and time-bound outcomes, often referred to as SMART goals. For example, for “Impaired Physical Mobility,” a goal might be, “The patient will ambulate 50 feet with a walker by the end of the shift.” This phase also involves selecting specific nursing interventions designed to help the patient achieve those goals. Interventions can be independent (performed without a physician’s order, like patient education) or dependent (requiring a prescription, like medication administration). The resulting care plan guides all healthcare staff, ensuring continuity of treatment.
Implementation: Carrying Out the Care Plan
Implementation is the action phase where the nurse executes the planned interventions to address patient needs and achieve established goals. This involves performing direct and indirect care activities outlined in the care plan, such as administering medications, performing wound dressing changes, or providing patient education. The nurse constantly monitors the patient’s response to these interventions. A major component of this phase is detailed and accurate documentation of all care provided and the patient’s immediate reaction. This record ensures the healthcare team is aware of actions taken and provides essential data for the next step of the nursing process.
Evaluation: Measuring Outcomes and Adjusting Care
Evaluation is the final, yet continuous, phase where the nurse determines the effectiveness of the care plan. This step requires comparing the patient’s current status against the measurable goals established during the planning phase. The nurse determines whether the expected outcomes were met, partially met, or not met. If goals are met, the problem is documented as resolved. If goals are not met, the process cycles back to the Assessment phase to determine the reason for the lack of progress. This feedback loop ensures that care is continuously adjusted and refined to meet the patient’s evolving health needs.