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