No matter where a nurse is working, The Nursing Process is always the same. The nursing process is a process by which nurses deliver care to patients.
Assessment – gathering of all subjective and objective information about the patient (complete head to toe Nursing Assessment)
o Health and Medical history
o Head-to-Toe and body systems approach
o Verbal interview with client
o Verbal interview with significant others
o Results of diagnostics/consults
Diagnosis – is made based on information obtained during the nursing assessment. Nursing Diagnosis is selected from the NANDA approved list. A developing nursing diagnosis may have two or three parts.
o Part I: (Problem) Nursing diagnosis
o Part II: (Etiology) Related to
o Part II: (Symptoms) Cues or manifestation
Planning – is the writing of client outcomes that are measurable and nursing interventions to achieve the outcomes.
o Remember that planning means prioritizing
o Maslow’s Hierarchy of needs is your guidelines for prioritizing the plan
Implementation – is the actual initiation of the plan of care.
o Interventions are written and performed
o The effectiveness of interventions are assessed by the nurse and documented
Evaluation – Evaluation is a process that is continuously performed by the nurse. The nurse determines if the outcomes have been met. The nurse determines if the outcomes have been met. Outcomes that were not met require the nurse to:
o Reconsider the nursing diagnosis
o Revise the plan
o Revise the interventions
o Re-evaluate the effectiveness of the interventions