The Nursing Process
Overview
The nursing process is a systematic, client-centered, dynamic framework used globally to
organize and deliver safe and effective nursing care. It is rooted in critical thinking and evidence-
based practice, supported by professional standards such as those established by the American
Nurses Association.
Five Core Steps
1. Assessment
o Purpose: Collect and analyze comprehensive data about client’s physical,
psychological, social, and spiritual status.
o Examples: Vital signs, health history, physical examinations, lab results, patient
interviews.
2. Nursing Diagnosis
o Definition: A clinical judgment identifying actual or potential health issues that
nurses are licensed to treat.
o Types: Actual, risk, health-promotion diagnoses (per NANDA classification).
3. Planning
o Goal Setting: Establish measurable, realistic, and time-bound objectives.
o Planning: Develop individualized care plans with appropriate interventions
prioritizing patient safety and desired outcomes.
4. Implementation
o Action: Execute the care plan—this includes direct care (e.g., administering
medications, wound care), education, counseling, and coordination with
interprofessional teams.
o Documentation: Record nursing actions and patient responses accurately.
5. Evaluation
o Assessment of Outcomes: Determine whether goals have been met.
o Plan Modification: Revise the care plan based on patient progress and
effectiveness of interventions.
Overview
The nursing process is a systematic, client-centered, dynamic framework used globally to
organize and deliver safe and effective nursing care. It is rooted in critical thinking and evidence-
based practice, supported by professional standards such as those established by the American
Nurses Association.
Five Core Steps
1. Assessment
o Purpose: Collect and analyze comprehensive data about client’s physical,
psychological, social, and spiritual status.
o Examples: Vital signs, health history, physical examinations, lab results, patient
interviews.
2. Nursing Diagnosis
o Definition: A clinical judgment identifying actual or potential health issues that
nurses are licensed to treat.
o Types: Actual, risk, health-promotion diagnoses (per NANDA classification).
3. Planning
o Goal Setting: Establish measurable, realistic, and time-bound objectives.
o Planning: Develop individualized care plans with appropriate interventions
prioritizing patient safety and desired outcomes.
4. Implementation
o Action: Execute the care plan—this includes direct care (e.g., administering
medications, wound care), education, counseling, and coordination with
interprofessional teams.
o Documentation: Record nursing actions and patient responses accurately.
5. Evaluation
o Assessment of Outcomes: Determine whether goals have been met.
o Plan Modification: Revise the care plan based on patient progress and
effectiveness of interventions.
