Five Step Nursing Process

ASSESSMENT

Purpose

To gather, verify, and communicate data about client so data base is established

Key Actions

Collect nursing health history.Perform physical examination.Collect laboratory data.


DIAGNOSIS

Purpose

To identify health care needs of client; to formulate nursing diagnoses

Key Actions

Interpret data, including data validation and clustering.Formulate nursing diagnoses (see NANDA Approved Nursing Diagnosis) 


PLANNING

Purpose

To identify client goals; to determine priorities of care; to design nursing strategies to achieve expected outcomes of care; to determine outcome criteria- SMART – goal should be Specific, Measurable, Attainable and Realistically Time-bound.

Key Actions

Identify expected outcomes.Select nursing actions.Delegate actions.Consult.Write nursing care plan.Ex. To reduce fever within the baseline data of 35.5 by giving prn antipyretic medication and performing tepid sponge bath for 4 hrs. 


IMPLEMENTATION

Purpose

To complete nursing actions necessary for accomplishing plan Reassess client.

Key Actions

Review and modify existing care plan.Perform nursing actions. 


EVALUATION

Purpose

To determine extent to which expected outcomes have been achieved. Very important to DOCUMENT your action! This is very essential for legal matters.

Key Actions

Establish evaluation criteria. Compare client response to outcome criteria. Analyze reasons for result and conclusions. Modify care plan.

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