Each step is integral to ensuring comprehensive and effective client care..
1. Assessment
During the first step of the process, the nurse works to understand the client’s condition and needs.
They’ll do this by collecting various data points, such as the client’s health history, and using their critical thinking skills to collect observations.
The types of nursing assessment data needed to complete this step include:
Objective data: These include vital signs, weight, pulse, intake, and output
Objective observations: These include skin color, the ability of the client to make eye contact, how easily they can get out of bed, and the sounds of the lungs.
Client data points: These subjective data points include the client’s current physical feelings — such as nausea — and emotions like anger or fear.
Any other useful nonverbal data: This can include the client’s overall appearance and body language.
The nurse can collect the information from primary, secondary, and tertiary sources.
Primary: The client is the primary source, and the nurse gathers information directly from them.
Secondary: Family members, friends, and health professionals who have worked with the client can provide secondary sources. Other sources include medical records, test results, and lab reports that can provide more detailed information about a client’s condition.
Tertiary: Tertiary sources might include textbooks or journals that provide an outside look at data points and data collection.
Carefully record all the data collected for later reference. Check out our Head to Toe Assessment Checklist for details on how to perform a full body assessment.
2. Diagnosis
During the diagnosis part of the nursing process, a nurse combines all the collected data points.
Then, they’ll use their experience, clinical judgment, and expertise to understand how the different points relate to each other so they can provide a nursing diagnosis. This diagnosis articulates the client’s needs and condition.
Sometimes, clients might even need more than one diagnosis. Nurses can consult the current NANDA International (NANDA-I) nursing diagnoses list.
These diagnoses follow Maslow’s Hierarchy of Needs, helping nurses understand how to help clients improve their overall health. Nurses use their diagnosis to guide them through the rest of the nursing process.
3. Planning
During the planning portion of the process, the nurse organizes their thoughts and ideas about the actions they’ll take to treat the client.
This care planning step helps everyone involved in the client’s care know the course of action pursued, the team’s goals for that action, and what they expect to happen for the client.
It’s important to note that planning is an ongoing portion of the nursing process. There is an initial planning stage, conducted immediately after evaluating the client.
Then, there are the ongoing planning stages of the nursing process, which the nurse conducts as they care for the client.
They will need to:
Watch how the client’s condition changes in response to their care.
Decide where to focus their attention on a given day.
Set evolving goals based on the client’s progress.
Finally, when it’s time for the client to leave, the nurse will need to set a discharge plan of care. These plans articulate the support that the client should have as they leave the clinical care setting and explain how the client should coordinate care with other health professionals.
The biggest thing is that the goals set by nurses should be SMART.
A SMART goal is:
Specific
Measurable
Attainable
Realistic
Time-oriented
A nurse can quickly evaluate goals that follow these criteria. They need to set long-term goals and short-term goals.
Of course, the nurse should articulate this in an NCP, which explains the care needed and the risk factors the client faces. A well-outlined plan can help ensure good communication between nurses and the client’s health care team members.
4. Implementation
During the implementation stage, the nurse involved in client care puts the plan into action.
Based on the diagnosis and plan outlined in the above steps of the nursing process, the nurse predetermines medical nursing interventions that will help the client achieve their goals. This process often involves informing the client about their care (and why they’re receiving it) so they can better articulate whether the interventions work.
The interventions taken by nurses typically fall under a few different types of classifications:
Interventions designed to target client behavior: Behavioral interventions help adjust client behavior for better health outcomes, such as helping with stress management or encouraging exercise.
Interventions that help communities or families: These interventions help the client and those around them. This includes providing HIV education or helping family members better understand their loved one’s illness and how to care for them.
Interventions to help patients in a clinical setting: Nurses follow interventions to help clients receive the best possible care in the hospital. For example, they might help clients adjust positions to avoid bed sores.
Interventions to promote safety: Nurses also keep clients safe and free of harm in the clinical care setting. For example, they may create a fall prevention plan or ensure that clients with allergies receive medication without allergic reactions.
Interventions to help patients physically: Interventions to improve the client’s physical health include inserting an IV or assisting the client with hygiene.
The Nursing Interventions Classification (NIC) publication helps create a standardized process for describing clients’ problems. This can help a nurse easily use the notes produced by other nurses, see the nursing diagnosis, and apply the recommended interventions because everyone has a common vocabulary to work with.
This can aid communication between nurses and provide more consistent care.
Rationales for Nursing Interventions
Nursing rationales provide the reasoning behind specific actions taken in patient care. They are grounded in evidence-based practice and tailored to the patient’s individual needs.
For example, administering medication may be justified by the need to alleviate pain, lower a fever, or combat an infection.
5. Evaluation
Finally, nurses will need to continually monitor and evaluate the success of interventions to ensure that they are effective.
During the evaluation phase, nurses should compare the client outcomes they see with the desired outcomes they identified as goals during the planning stage. This means nurses should regularly reassess clients to determine whether they need to adjust the plan.
Study tip: To help you remember the steps of the nursing process, use the acronym ADPIE (assessment, diagnosis, planning, implementation, and evaluation).
