The nursing process is a systematic, patient-centered framework that guides professional nursing practice. It provides a common language and methodology, ensuring a consistent and comprehensive approach to care delivery. This framework applies the scientific method to clinical care, allowing nurses to make informed judgments and address patient needs effectively. The purpose of this organized approach is to deliver individualized, holistic care that promotes wellness, prevents disease, and restores health. It identifies a patient’s health status and actual or potential health problems, forming the foundation for all subsequent actions and interventions.
The Framework of the Nursing Process
The nursing process is structured around five distinct, sequential phases, often remembered by the acronym ADPIE: Assessment, Diagnosis, Planning, Implementation, and Evaluation. Although these steps are presented in a linear order, the framework is fundamentally dynamic and cyclical. Nurses constantly move between phases, particularly evaluation and reassessment, to reflect the patient’s changing condition. This structured method originated with nurse theorist Ida Jean Orlando in the 1950s and is now the standard of professional practice. The cyclical nature means that evaluation often leads directly back to a new assessment, restarting the cycle to address new or unresolved issues.
Step 1 Gathering Patient Information (Assessment)
The initial phase involves the systematic collection of patient data to establish a comprehensive health database. This data is categorized into two main types: subjective and objective. Subjective data, or symptoms, consists of information provided verbally by the patient, such as feelings, perceptions, and descriptions of discomfort. Objective data, or signs, includes measurable and observable facts gathered through physical examination, laboratory results, and diagnostic tests. This information includes vital signs, weight, intake and output, and the nurse’s direct observation of the patient’s physical abilities. The nurse also collects a detailed health history and may consult with the patient’s family or other healthcare records. This thorough collection of baseline data provides the standard against which all future changes and the effectiveness of interventions will be measured.
Step 2 Identifying Patient Needs (Diagnosis)
The second step involves analyzing assessment data to form a nursing diagnosis, which is a clinical judgment about an individual’s response to actual or potential health problems. This differs from a medical diagnosis, which identifies a disease (e.g., pneumonia). The nursing diagnosis identifies the human response (e.g., “Impaired Gas Exchange”) and focuses on problems nurses can treat independently, such as comfort, mobility, or coping. Nurses use the standardized P.E.S. statement to formulate this judgment. The “P” is the Problem (the standardized diagnostic label, often from NANDA International). The “E” is the Etiology (related factors contributing to the problem). The “S” represents the Signs and Symptoms (evidence from assessment data that proves the problem exists).
Step 3 Creating the Plan of Care (Planning)
The planning phase begins by prioritizing the patient’s nursing diagnoses to ensure the most urgent needs are addressed first. Nurses often use frameworks like Maslow’s Hierarchy of Needs, ensuring basic physiological needs are met before focusing on higher-level needs. The nurse then works collaboratively with the patient to establish specific goals and desired outcomes. These outcomes must be written as “SMART” goals: Specific, Measurable, Attainable, Relevant, and Time-bound. For example, a goal might be that the patient will ambulate 50 feet with one assist by the end of the shift. This step also involves selecting evidence-based nursing interventions to help the patient achieve the established short-term and long-term goals.
Step 4 Putting the Plan into Action (Implementation)
Implementation is the action-oriented phase where the nurse executes the specific interventions outlined in the care plan. Interventions are grouped into two major categories: direct care and indirect care. Direct care involves hands-on interaction with the patient, such as administering medications, performing wound care, or assisting with mobility. Indirect care includes actions performed away from the patient but on their behalf, supporting the overall effectiveness of the care plan. Examples of indirect care include:
- Documenting the patient’s progress.
- Coordinating with other healthcare professionals.
- Delegating tasks.
- Managing resources.
Throughout this phase, the nurse continuously monitors the patient’s response, making minor adjustments and performing ongoing reassessment to ensure safety and effectiveness.
Step 5 Measuring Results (Evaluation)
Evaluation is the final, continuous step where the nurse determines the effectiveness of the entire care plan. This phase requires comparing the patient’s current status against the specific expected outcomes established during planning. The nurse collects new data through reassessment measures, such as checking a wound or listening to lung sounds, and analyzes whether the goals were met, partially met, or unmet. Based on this evaluation, the nurse decides the next steps. If goals are met, the plan for that problem is terminated. If goals are partially or entirely unmet, the nurse must analyze the reasons and modify the plan, often returning to the assessment step to gather more data and restart the cycle.
Why the Nursing Process Matters for Quality Care
The structured methodology of the nursing process ensures the delivery of high-quality patient care. It standardizes professional practice, providing nurses with a uniform, evidence-based roadmap for clinical decision-making and problem-solving. This consistency reduces errors and omissions, leading to safer and more efficient patient outcomes. The process promotes critical thinking by requiring nurses to analyze complex data, formulate judgments, and plan personalized interventions. The detailed documentation required at each step provides legal protection and ensures seamless continuity of care, allowing the healthcare team to follow the patient’s progress. The framework guarantees that care is individualized and centered on the unique needs of the person.