2026/2027 OVERVIEW OF THE NURSING PROCESS: ASSESSMENT, DIAGNOSIS, PLANNING,
IMPLEMENTATION, AND EVALUATION
Assessment
• Subjective data – patient’s verbal description of their health problems
• Objective data – observations or measurements of a patient’s health status
• Health history – Provides information regarding the patient’s past history. Has there been
a hospitalization? A procedure? Medication uses? Prescription, over the counter, herbal,
natural? Use of alcohol, tobacco, caffeine, recreational drugs? Sleeping patterns?
Exercise habits? Nutritional habits? Family history: Blood relative health issues? Recent
losses? Religious influences? Relationships? Allergies? Also, include patient habits and
lifestyle patterns. Patient’s Health History - Physical and Developmental (perception of
health status, past health problems and therapies, risk factors, developmental stage,
growth and maturation, ADLs, occupation) Emotional (behavioral and emotional status,
self-concept, body image, sexuality, coping mechanisms) Intellectual (intellectual
performance, problem solving, attention span, long-term and recent memory) Spiritual
(beliefs and meaning, religious experiences, fellowship, courage) Social (financial status,
recreational activities, primary language, social relationships, community resources,
cultural heritage and influences)
• Data clustering – set of cues, the signs and symptoms gathered during assessment
Diagnosis
• Nursing diagnosis - clinical judgment vulnerability for that response by an individual,
family, or community that a nurse is licensed and competent to treat. Patients are actively
involved. Nursing diagnoses are ever changing on the basis of a patient’s needs.
• Medical diagnosis – given by physican
• The nursing diagnosis statement – 3 part format: problem solving, risk, and health
promotion
• A problem-focused nursing diagnosis describes a clinical judgment concerning an
undesirable human response to a health condition/life process that exists in an individual,
family, or community.
• Defining characteristics support each problem-focused diagnosis.
A related factor is an etiological or causative factor for the diagnosis, and allows you to
individualize a problem-focused nursing diagnosis for a specific patient need.
• A risk nursing diagnosis is a clinical judgment concerning the vulnerability of an
individual, family, group, or community for developing an undesirable human
response to health conditions/life processes.
• Instead a risk diagnosis has risk factors. Risk factors are the
environmental, physiological, psychological, genetic, or chemical
elements that place a person at risk for a health problem.
• A health promotion nursing diagnosis is a clinical judgment concerning motivation and
desire to increase well-being and actualize human health potential.
• These responses are expressed by a readiness to enhance specific health
behaviors and can be used in any health state.
• Health promotion diagnoses may apply to an individual, family, group,
or community.
IMPLEMENTATION, AND EVALUATION
Assessment
• Subjective data – patient’s verbal description of their health problems
• Objective data – observations or measurements of a patient’s health status
• Health history – Provides information regarding the patient’s past history. Has there been
a hospitalization? A procedure? Medication uses? Prescription, over the counter, herbal,
natural? Use of alcohol, tobacco, caffeine, recreational drugs? Sleeping patterns?
Exercise habits? Nutritional habits? Family history: Blood relative health issues? Recent
losses? Religious influences? Relationships? Allergies? Also, include patient habits and
lifestyle patterns. Patient’s Health History - Physical and Developmental (perception of
health status, past health problems and therapies, risk factors, developmental stage,
growth and maturation, ADLs, occupation) Emotional (behavioral and emotional status,
self-concept, body image, sexuality, coping mechanisms) Intellectual (intellectual
performance, problem solving, attention span, long-term and recent memory) Spiritual
(beliefs and meaning, religious experiences, fellowship, courage) Social (financial status,
recreational activities, primary language, social relationships, community resources,
cultural heritage and influences)
• Data clustering – set of cues, the signs and symptoms gathered during assessment
Diagnosis
• Nursing diagnosis - clinical judgment vulnerability for that response by an individual,
family, or community that a nurse is licensed and competent to treat. Patients are actively
involved. Nursing diagnoses are ever changing on the basis of a patient’s needs.
• Medical diagnosis – given by physican
• The nursing diagnosis statement – 3 part format: problem solving, risk, and health
promotion
• A problem-focused nursing diagnosis describes a clinical judgment concerning an
undesirable human response to a health condition/life process that exists in an individual,
family, or community.
• Defining characteristics support each problem-focused diagnosis.
A related factor is an etiological or causative factor for the diagnosis, and allows you to
individualize a problem-focused nursing diagnosis for a specific patient need.
• A risk nursing diagnosis is a clinical judgment concerning the vulnerability of an
individual, family, group, or community for developing an undesirable human
response to health conditions/life processes.
• Instead a risk diagnosis has risk factors. Risk factors are the
environmental, physiological, psychological, genetic, or chemical
elements that place a person at risk for a health problem.
• A health promotion nursing diagnosis is a clinical judgment concerning motivation and
desire to increase well-being and actualize human health potential.
• These responses are expressed by a readiness to enhance specific health
behaviors and can be used in any health state.
• Health promotion diagnoses may apply to an individual, family, group,
or community.
