Nursing Process Overview

Overview of the Nursing Process

 

Component and Description Purpose Activities
Assessing

Collecting, 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

Diagnosing

Analyzing 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

Planning

Determining 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 client

Write 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

Implementing

Carrying 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 database

Determine 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
Evaluating

Measuring 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 outcomes

Judge 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

 

6 Responses to Nursing Process Overview

  1. Andrea Cao says:

    Regarding Assessing phase, I’d like to add more methods for establishing a database:
    -physical assessment, review results of laboratory & diagnosis test.

  2. Andrea Cao says:

    Re Implementation phase, when we reassess the client, be sure to review/revise the existing nursing care plan accordingly (if any change). Make sure the nurse organizing resources and care delivery (equipment, staff, environment, and the pt is ready). The nurse also needs to anticipate/prevent complication in the implementation phase.

  3. DJM says:

    This is a great site, it helped me out a lot, can you give me some help with doing a nursing care plan for a patient who is a Attempted Suicide patient who has Severe Brain Injury, Acute Resp, Failure, Vent Dependent, Spasms & Incontinent

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