Assessment. This is the first step of the nursing process. It involves the systematic and continuous collection, validation (evaluation) and selection of data. Data is collected from a variety of sources (clients, families, health records, physicians, nurses, and other healthcare professionals). Data collection guidelines reflect the CSUB Department of Nursing Conceptual Model. Activities include: (1) establishing the database (nursing history, physical assessment, review of the patient/client’s record and nursing literature, and consultation with patient/client’s support persons and healthcare professionals); (2) continuously updating the database; (3) validating data; and (4) communicating data.
Nursing Diagnosis. From the assessment of functional health patterns human response patterns are identified and classified according to statements of actual, high risk and possible problems, and wellness diagnoses (Carpenito, 1993). It requires data analysis to identify the patient/client’s strengths and health problems that independent nursing interventions can resolve. Activities include: (1) interpreting and analyzing patient/client data; (2) identifying patient/client strengths and health problems; (3) formulating and validating nursing diagnoses; and (4) developing a prioritized list of nursing diagnoses.
Planning. Specification of client goals to promote health and/or prevent, reduce, or resolve the problems that are identified in the nursing diagnoses, and related nursing interventions. Implementation strategies address the patient/client’s health state and aim to facilitate attaining the desired outcomes. Implementation encompasses four levels of care: preventive, supportive, restorative and rehabilitative. Activities include: (1) establishing priorities; (2) writing goals and developing an evaluative strategy; (3) selecting nursing measures; (4) communicating the plan of nursing care.
Intervention. Implementing the plan of care. Activities include: (1) carrying out the plan of care; (2) continuing data collection and modifying the plan of care as needed; (3) documenting the care given.
Evaluation. Measures the extent to which the patient/client has achieved the goals specified in the plan of care, and identifies the factors that positively or negatively influenced goal achievement. The plan of care is revised as necessary. Activities include: (1) measuring how well the client has achieved the desired goals; (2) identifying factors that contributed to the client’s success or failure; (3) modifying the plan of care (if indicated).
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