Stages of the Nursing Process to Know for Foundations of Nursing Practice

The nursing process is a systematic approach that guides nurses in providing effective patient care. It includes five key stages: assessment, diagnosis, planning, implementation, and evaluation, each essential for ensuring comprehensive and personalized care for patients.

1. Assessment

   • Collect comprehensive data about the patient’s health status through observation, interviews, and physical examinations.
   • Utilize both subjective (patient-reported) and objective (clinician-observed) data to form a complete picture of the patient’s condition.
   • Identify normal and abnormal findings to guide further nursing actions and interventions.
   • Document findings accurately to ensure continuity of care and effective communication among healthcare team members.

2. Diagnosis

   • Analyze assessment data to identify actual or potential health problems, known as nursing diagnoses.
   • Use standardized nursing diagnosis frameworks (e.g., NANDA-I) to ensure consistency and clarity in identifying patient needs.
   • Prioritize diagnoses based on the severity and urgency of the patient’s condition, considering safety and risk factors.
   • Formulate clear, concise statements that guide the development of patient-centered care plans.

3. Planning

   • Develop individualized care plans that outline specific, measurable, achievable, relevant, and time-bound (SMART) goals for the patient.
   • Collaborate with the patient and interdisciplinary team to ensure that the plan reflects the patient’s preferences and needs.
   • Identify appropriate nursing interventions that are evidence-based and tailored to address the identified diagnoses.
   • Establish a timeline for achieving goals and determine criteria for evaluating the effectiveness of interventions.

4. Implementation

   • Execute the nursing interventions outlined in the care plan, ensuring that they are performed safely and effectively.
   • Communicate with the patient and their family about the interventions being carried out and their purpose.
   • Document the implementation process, including any modifications made to the care plan based on the patient’s response.
   • Collaborate with other healthcare professionals to provide comprehensive care and address any emerging issues.

5. Evaluation

   • Assess the patient’s progress toward the goals set in the care plan, using both qualitative and quantitative measures.
   • Determine the effectiveness of nursing interventions and whether the patient’s condition has improved, worsened, or remained stable.
   • Revise the care plan as necessary based on evaluation findings, ensuring it remains relevant to the patient’s current needs.
   • Engage the patient in the evaluation process to promote accountability and encourage active participation in their own care.