Overview of the Nursing Process

Overview of the Nursing Process

Component and Description Purpose Activities
AssessingCollecting, organizing, validating, and documenting client data To establish a database about the client’s response to health concerns or illness and the ability to manage health care needs Establish a database:

  • Obtain a nursing health history
  • Review client records
  • Review nursing literature
  • Consult support persons
  • Consult health professionals

Update data as needed

Organize data

Validate data

Communicate/document data

DiagnosingAnalyzing and synthesizing data To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions.To develop a list of nursing diagnoses and collaborative problems. Interpret and analyze data:

  • Compare data against standards
  • Cluster or group data (generate tentative hypotheses)
  • Identify gaps and inconsistencies

Determine client’s strengths, risks, and problems

Formulate nursing diagnoses and collaborative problem statements

PlanningDetermining how to prevent, reduce, or resolve the identified client problems; how to support client strengths; and how to implement nursing interventions in an organized, individualized, and goal-directed manner To develop and individualized care plan that specifies client goals/desired outcomes and related nursing interventions. Set priorities and goals/outcomes in collaboration with clientWrite goals/desired outcomes

Select nursing strategies/interventions

Consult with other health professionals

Write nursing orders and nursing care plan

Communicate care plan to relevant healthcare providers

ImplementingCarrying out the planned nursing interventions To assist the client to meet desired goals/outcomes; promote wellness and disease; restore health; and facilitate coping with altered functioning. Reassess the client to update the databaseDetermine need for nursing assistance

Perform or delegate planned nursing interventions

Communicate what nursing actions were implemented:

  • Document care and client responses to care
  • Give verbal reports as necessary
EvaluatingMeasuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement To determine whether to continue, modify, or terminate the plan of care. Collaborate with client and collect data  related to desired outcomesJudge whether goals/outcomes have been achieved

Relate nursing actions to client outcomes

Make decisions about problem status

Review and modify the care plan as indicated or terminate nursing care

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