Phases[edit]

The nursing process is goal-oriented method of caring that provides a framework to nursing care. It
involves six major steps:
A
Assess (what data is collected?)
D
Diagnose (what is the problem?)
O
Outcome Identification - (Was originally a part of the Planning phase, but has recently been
added as a new step in the complete process).
P
Plan (how to manage the problem)
I
Implement (putting plan into action)
R
Rationale (Scientific reason of the implementations)
E
Evaluate (did the plan work?)
According to some theorists, this six-steps description of the nursing
process is outdated and misrepresents nursing as linear and atomic.
[7]

Assessing phase[edit]
Main article: Nursing assessment
The nurse completes an holistic nursing assessment of the needs of
the individual/family/community, regardless of the reason for the
encounter. The nurse collects subjective data and objective data using
a nursing framework, such as MarjoryGordon's functional health
patterns.
Models for data collection[edit]
Nursing assessments provide the starting point for determining nursing
diagnoses. It is vital that a recognized nursing assessment framework
is used in practice to identify the patient's* problems, risks and
outcomes for enhancing health. The use of an evidence-based nursing
framework such as Gordon's Functional Health Pattern Assessment
should guide assessments that support nurses in determination of
NANDA-I nursing diagnoses. For accurate determination of nursing
diagnoses, a useful, evidence-based assessment framework is best
practice.
Methods[edit]
Client Interview
Physical Examination
Obtaining a health history (including dietary data)
Family history/report
Diagnostic Data
Observation
Diagnosing phase[edit]
Main article: Nursing diagnosis
Nursing diagnoses represent the nurse's clinical judgment about actual
or potential health problems/life process occurring with the individual,
family, group or community. The accuracy of the nursing diagnosis is
validated when a nurse is able to clearly identify and link to the defining
characteristics, related factors and/or risk factors found within the
patients assessment. Multiple nursing diagnoses may be made for one
client.
Planning phase[edit]
Main article: Nursing care plan
In agreement with the client, the nurse addresses each of the problems
identified in the diagnosing phase. When there are multiple nursing
diagnoses to be addressed, the nurse prioritizes which diagnoses will
receive the most attention first according to their severity and potential
for causing more serious harm. For each problem a measurable
goal/outcome is set. For each goal/outcome, the nurse selects nursing
interventions that will help achieve the goal/outcome. A common
method of formulating the expected outcomes is to use the evidence-
based Nursing Outcomes Classification to allow for the use of
standardized language which improves consistency of terminology,
definition and outcome measures. The interventions used in
the Nursing Interventions Classification again allow for the use of
standardized language which improves consistency of terminology,
definition and ability to identify nursing activities, which can also be
linked to nursing workload and staffing indices. The result of this phase
is a nursing care plan.
Implementing phase[edit]
The nurse implements the nursing care plan, performing the
determined interventions that were selected to help meet the
goals/outcomes that were established. Delegated tasks and the
monitoring of them is included here as well.
Evaluating phase[edit]
The nurse evaluates the progress toward the goals/outcomes identified
in the previous phases. If progress towards the goal is slow, or if
regression has occurred, the nurse must change the plan of care
accordingly. Conversely, if the goal has been achieved then the care
can cease. New problems may be identified at this stage, and thus the
process will start all over again.