Steps of the Nursing Process
The nursing process is a deliberate problem-solving approach for meeting a person’s health care and nursing needs. Although the steps of the nursing process have been stated in various ways by different writers, the common components cited are assessment, diagnosis, planning, implementation, and evaluation. The ANA’s Standards of Clinical Nursing Practice (1998) include an addi-tional component entitled “outcome identification” and establish the sequence of steps in the following order: assessment, diagno-sis, outcome identification, planning, implementation, and eval-uation. For the purposes of this text, the nursing process will be based on the traditional five steps and will delineate two compo-nents in the diagnosis step: nursing diagnoses and collaborative problems. After the diagnoses or problems have been determined, the desired outcomes are often evident. The traditional steps are defined as follows:
1) Assessment: The systematic collection of data to determinethe patient’s health status and identify any actual or po-tential health problems. (Analysis of data is included as part of the assessment. For those who wish to emphasize its im-portance, analysis may be identified as a separate step of the nursing process.)
2) Diagnosis: Identification of the following two types ofpatient problems:
a) Nursing diagnoses: Actual or potential health problemsthat can be managed by independent nursing inter-ventions
b) Collaborative problems: “Certain physiologic complica-tions that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nursing-prescribed interven-tions to minimize the complications of the events”.
3) Planning: Development of goals and outcomes, as well as aplan of care designed to assist the patient in resolving the diagnosed problems and achieving the identified goals and desired outcomes.
4) Implementation: Actualization of the plan of care throughnursing interventions.
5) Evaluation: Determination of the patient’s responses to thenursing interventions and the extent to which the out-comes have been achieved.
Dividing the nursing process into distinct steps serves to em-phasize the essential nursing actions that must be taken to resolve the patient’s nursing diagnoses and manage any collaborative prob-lems or complications. Dividing the process into separate steps is, however, artificial: the process functions as an integrated whole, with the steps being interrelated, interdependent, and recurrent (Fig. 3-1). Chart 3-6 presents an overview of the nursing activities involved in applying the nursing process.