Nursing Process: Assessment, Diagnosis, Planning, Implementation & Evaluation

Nursing Process

The nursing process is an evidence-based framework used by registered nurses (RNs) and advanced practice nurses to systematically deliver patient care to achieve desired health outcomes. This structured approach applies the scientific method to patient care, which includes identifying, diagnosing, planning, implementing, and evaluating care for patients based on their unique needs and circumstances.

Assessment

Assessment is the first step in the nursing process, which includes gathering information from various sources such as the patient's medical history, physical examination, diagnostic tests, and vital signs. It helps to identify the health status of individuals, determine their needs, set priorities, and develop goals. Assessment data help guide the entire nursing process and promote effective communication among healthcare teams.

Diagnosis

Diagnosis is the second step in the nursing process, where nurses analyze the collected data during the assessment phase and make clinical judgments based on the World Health Organization International Classification of Diseases (ICD) or the North American NANDA-F Taxonomy. These diagnoses describe symptoms, risk factors, etiological factors, and contributing conditions related to patients' problems across four domains: physiological, psychosocial, cognitive, and environmental. Nurses also devise self-care plans aimed at addressing these identified issues through teaching, support, and other interventions.

Planning

Planning is the third step in the nursing process, where nurses establish specific goals and objectives related to patient care. Based on the assessment findings and diagnoses, the nurse creates individualized patient care plans guided by therapeutic approaches and nursing theories. Care plans may involve collaborating with members of the multidisciplinary team, including doctors, pharmacists, dietitians, social workers, and occupational therapists.

Implementation

Implementation is the fourth step in the nursing process, where RNs put into action the care plan established during the planning stage. They administer medications, carry out prescribed treatments, perform supervised procedures, and document nursing actions accurately within electronic health records (EHR). During this step, RN's also monitor patients' responses to treatment, adjust interventions if necessary, and educate patients regarding their condition while ensuring confidentiality.

Evaluation

Evaluation is the final step in the nursing process, where RNs assess whether patient goals and objectives established in the planning phase have been met. They reassess patients to determine if there have been changes in their health status, identifying areas that require modification or improvement in the care plan. This ongoing evaluation helps ensure that patient needs continue to be addressed effectively throughout the healing process.