Nursing process

The concept of nursing process was first introduced in the 1950s as a three-step process of assessment, planning, and evaluation based on the scientific method of observing, measuring, gathering data, and analyzing the findings.


Years of study, use, and refinement have led nurses to expand the nursing process to five distinct steps that provide an efficient method of organizing thought processes for clinical decision making, problem solving, and delivery of higher quality, individualized client care.


The nursing process now consists of:

  • assessment or the systematic collection of data relating to clients;
  • diagnosis/need identification involving the analysis of collected data to identify the client’s needs or problems;
  • planning, which is a two-part process of identifying goals and the client’s desired outcomes to address the assessed health and wellness needs along with the selection of appropriate nursing interventions to assist the client in attaining the outcomes;
  • implementation or putting the plan of care into action; and
  • evaluation by determining the client’s progress toward attaining the identified outcomes, and the client’s response to and effectiveness of the selected nursing interventions for the purpose of altering the plan as indicated.

ANA STANDARDS OF CLINICAL NURSING PRACTICE

Standards of Care


Describes a competent level of nursing care as demonstrated by the nursing process that encompasses all significant actions taken by the nurse in providing care, and forms the foundation of clinical decision

making.


1. Assessment: the nurse collects client health data.

2. Diagnosis: the nurse analyzes the assessment data in determining diagnoses.

3. Outcome Identification: the nurse identifies expected outcomes individualized to the client.

4. Planning: the nurse develops a plan of care that prescribes interventions to attain expected outcomes.

5. Implementation: the nurse implements the interventions identified in the plan of care.

6. Evaluation: the nurse evaluates the client’s progress toward attainment of outcomes.