It involves a thorough and systematic collection of both subjective and objective data about the patient. This data encompasses physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors. The goal is to understand the patient’s current health status and needs fully. This step sets the foundation for the entire nursing process.

Diagnosis #

Based on the assessment data, nurses formulate nursing diagnosis. These diagnoses reflect the patient’s responses to actual or potential health conditions or needs. Nursing diagnoses are crucial for planning and implementing patient care. They help in identifying how a patient is responding to health issues or risks and guide the selection of interventions.

Planning #

Nurses set measurable and achievable short- and long-term goals for the patient’s care. These goals are based on the assessment data and nursing diagnoses. The planning process involves determining the strategies and interventions required to achieve these goals. The care plan is documented, making it accessible to the entire healthcare team.

Implementation #

The nursing care plan is put into action. This step may involve administering medications, providing education, performing procedures, or coordinating care with other healthcare professionals. Nurses must consider the patient’s preferences and developmental level when initiating interventions. The implementation phase is dynamic, requiring continuous reassessment and adjustment of the care plan as needed.

Evaluation #

The final step of the nursing process is evaluation. This involves assessing the patient’s response to the nursing interventions and determining whether the care plan’s goals have been achieved. Based on this evaluation, the care plan may be continued, modified, or terminated. Continuous evaluation ensures that the patient’s care remains relevant and effective over time.