Assessment

• Assessment is the first step in developing the nursing care plan. It involves collecting important data and information about the client's health status, including physiological, psychosocial and spiritual. It is also the time when strengths and deficits in self-care are identified. Data gathered falls into two categories: objective and subjective. Objective data refers to information that is gathered by direct observation or measurement, such as vitals signs, lab test results, lung sounds and overall physical assessment. Data dealing with the client's own interpretation or description of symptoms, feelings or what family members provide is subjective. All of the information gathered must be validated, interpreted, organized and documented.
  
  

Diagnosis

• Nurses make specific statements about the health status of patients. This statement is a nursing diagnosis. The North American Nursing Diagnosis Association (NANDA) is the organization responsible for classifying and approving all known nursing diagnoses for use in clinical settings and research. Nursing diagnosis is not the same as a medical diagnosis, however. The nursing diagnosis is a statement describing a patient's reaction to health problems. According to the American Nurses Association, "Nurses are educated to be attuned to the whole person, not just the unique presenting health problem," and this is the difference between nurses and all other health-care professionals. An example of a nursing diagnosis would be "impaired swallowing related to stroke," or "feeding and hygiene self-care deficits related to dementia." The nursing diagnosis may identify potential problems and risks. "At risk for impaired skin integrity related to limited physical mobility," is an example.
  
  

Planning

• Planning is part of the nursing process dealing with making a plan and setting goals for every patient. The nurse prioritizes nursing diagnoses as high, moderate or low. Those with high priority are placed at the top of the list followed by moderate; low-priority diagnoses are last. Long- and short-term goals are identified, along with expected outcomes and appropriate nursing actions. Nursing actions are "nursing interventions" that help patients achieve planned goals. All of this is documented in the client record.
  
  

Implementation

• Nurses carry out nursing interventions during the implementation phase of the nursing process. Some examples of nursing interventions would be: administer pain medication as needed, turn and reposition every two hours or perform range-of-motion exercises. An order may be required of certain nursing interventions before they can be carried out. A standing order would be an example of this. Standing orders are made by doctors in case certain situations arise, such as giving a medication when the patient shows signs of agitation or insomnia. Some interventions are actually carried out by other licensed health-care professionals, for example a physical or respiratory therapist. The nurse records all interventions performed as well as the patient's response and outcome. This information is also relayed at the end of the shift to the nurse who will be caring for the patient next during the oncoming shift.
  
  

Evaluation

• During the evaluation phase of the nursing process, the nurse assesses whether the patient's goals have been achieved, and to what degree. Some goals are met partially or not at all and in these cases the nurse must determine what nursing actions should be implemented to bring about full achievement of goals. Goals that are met fully must be assessed to determine whether the implementation of nursing actions is necessary to continue or not. The evaluation is also documented. Evaluation is continuously done and depends upon all other phases of the process.