The 5 Nursing Process Steps

The 5 Nursing Process Steps –
(Learn Each Step in Detail)
ARLENE L. GALON, RN, MAN

 One of the most important tools a nurse can use in practice is the nursing
process. Although nursing schools teach first-year students about the nursing
process, some nurses fail to grasp the impact its proper use can have on patient
care. In this article, I will share information about the nursing process, its history,
its purpose, its main characteristics, and the 5 steps involved in carrying out the
nursing process. After reading this article, you will be able to answer the question,
“what is the nursing process” and understand what is involved in each of the 5
steps of the nursing process.
 Additionally, throughout this article, after discussing a step of the nursing process,
I will share an example of how the nurse would proceed with that step. For this
article’s purposes, we will use information about the following patient: Mr. Collie, a
fifty-four-year-old white male being admitted to the Medical-Surgical floor for acute
congestive heart failure.
What Is The Nursing Process In Simple Words?
The nursing process is a series of steps nurses take to assess

patients, plan for and provide patient care, and evaluate the
patient’s response to care. It is considered the framework upon
which all nursing care is based.
When Was The Nursing Process Developed?
 The earliest version of the nursing process was introduced in 1955 by Lydia Hall. Ms. Hall identified
three steps of the nursing process: observation, administration of care, and validation. Other versions
of the nursing process appeared throughout the next decade.
 Dorothy Johnson, in 1959, described nursing as "fostering the behavioral functioning of the
client.” Ms. Johnson’s version of the nursing process included the three steps: assessment, decision,
and nursing action.
 Finally, in 1961, Ida Jean Orlando-Pelletier introduced the version of the nursing process known to
nurses today.
Who Developed The Nursing Process?
The nursing process as we know it today is based upon the “

Deliberative Nursing Process Theory” developed by Ida Jean
Orlando-Pelletier. Ms. Orlando-Pelletier's version of the nursing
process includes five steps: Assessment, Diagnosis, Planning,
Implementation, and Evaluation.
What Is The Purpose Of The Nursing Process?
 The purpose of the nursing process is to establish a standard of care where nurses
assess patients and create plans of action to address individualized patient needs. The
nursing process has other purposes, as well, including but not limited to the following.
 • Establishes plans to meet patient needs

• Guides nurses in the delivery of high-quality evidence-based care
• Protects nurses against potential legal problems
• Promotes a systematic approach to patient care that all members of the nursing team
can follow
What Are The 7 Main Characteristics Of The Nursing
Process?
 There are several characteristics associated with providing nursing care. The following is a
list of the seven main characteristics of the nursing process and an explanation for each
one.
1. Within the legal Scope of Practice

Perhaps the most essential characteristic of the nursing process is that it should be used within
the nurse’s legal Scope of Practice.
2. Based on sound knowledge
Effective use of the nursing process requires the nurse to utilize nursing knowledge and skills
to identify and resolve problems. Nurses should develop and continuously strengthen critical
thinking skills and the use of evidence-based nursing interventions.
3. Planned
A well-thought-out approach to patient care leads to organized, systemic patient care that is delivered
efficiently and in order.
4. Client-centered
It is imperative that nurses understand the importance of client-centered nursing care. The nursing
process characteristic of client-centered care helps nurses plan care that is individualized to the patient. It
also supports patient autonomy, which is every patient’s right.
5. Goal-directed
As the title suggests, goal-directed care is a form of nursing care delivery based on achieving
individualized goals to achieve desired patient outcomes. Goals are created through the collaborative
efforts of nurses, other members of the healthcare team, and patients.
6. Prioritized
When planning patient care, it is necessary to identify all health issues and risk factors and prioritize
patient care, focusing on the most serious issues first. As you learn about the nursing process steps later
in this article, it will become evident that the process is continuous, and nurses must repeat steps. As
continued assessments and evaluations occur, and depending on the patient’s response to care, the order
of priorities in the care plan may change.
7. Dynamic and Cyclical

The nursing process is a dynamic process as it is constantly affected by the patient's needs, circumstances
impacting their needs, and the environment in which care is applied. It encompasses emotional, physical,
social, and medical aspects. Each phase of the nursing process interacts with and is influenced by other
phases in a cycle of activity. From the time of admission until the patient is discharged from care, the
dynamics of the cycle of nursing care continues.
How Many Steps Are There In The Nursing Process?
The nursing process consists of five steps which encompass the care provided. The
five nursing process steps are:
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
WHAT ARE THE 5 STEPS OF THE
NURSING PROCESS?
 The following are explanations for each step of the five steps
of the nursing process, information about why each is
important, the main objectives of each step, the skills needed to
complete each step, challenges nurses may face in each step,
and a real-life example for each step.
STEP #1: ASSESSMENT PHASE
What Is The Assessment Phase?
 The first phase of the nursing process is the assessment phase. In this phase, the nurse collects and
organizes data related to the patient. Data includes information about the patient, family, caregivers, or the
patient's community or environment as it is relevant to his health and well-being.
What Are The Top 3 Reasons Why The Assessment Phase Is Important?
All phases of the nursing process are essential. The following are a few reasons why the assessment phase is
important for nurses to provide care.
1. In the assessment phase of the nursing process steps, the nurse gathers all pertinent information that will be
used to establish a care plan.
2. Every other step of the nursing process builds upon the previous. Without a thorough assessment, the other
steps of nursing care may be negatively impacted, resulting in unfavorable outcomes.
3. When assessments are performed correctly, they help reduce risks to patient safety which could occur when
symptoms or other factors are not considered.
What Are The 5 Main Objectives Of The Assessment
Phase?
 The assessment phase of the nursing process involves gathering information about the
patient which is used to guide planning care, setting goals for recovery, and evaluating
patient progress. Nurses can obtain information about the patient by implementing the
following objectives.
1. Establish communication with the patient.

 The patient is the nurse’s main source of information. Therefore, it is essential to establish
rapport with them as soon as possible.
2. Establish communication
 with the patient's family or caregivers when appropriate. Family members, friends, or
other caregivers often offer insight into what is going on with the patient. It is important
for nurses to listen to the patient’s support people and gather any information available.
3. Conduct a patient interview.
 When the patient feels comfortable, it makes it easier to get the necessary information that
will be used to establish a plan of care. The patient interview is one of the main sources of
information used to plan patient care.
4. Collect objective data.

 Any information that is measurable or observable such as vital signs and test results is
considered objective data.
5. Collect subjective data.

 Subjective data is information gathered from the patient.
What Skills Are Required For The Assessment Phase?
 Assessments are vital to the nursing process. The information

gathered in the assessment phase impacts every component of
patient care. Nurses must demonstrate excellent verbal and written
communication skills, strong attention to detail, and possess an in-
depth understanding of body systems. The most frequently used
clinical skills for patient assessment are inspection, percussion,
palpation, and auscultation.
What Exactly Does The Assessment Phase Involve?
 The assessment phase is a critical component of the nursing process. Information gathered in this phase is used
to establish a foundation upon which all patient care moving forward is established. Remember, it is normal for
patients to feel nervous or fearful when they are sick and in an unfamiliar place, like a hospital. Therefore, the
nurse needs to establish an environment conducive to patient comfort.
The assessment may include but is not limited to, the following aspects: environmental, physical, cultural,
psychological, safety, and psychosocial assessments.
The following is a guideline of what should happen during the assessment phase.
Data Collection:
 During the assessment phase, the nurse collects objective and subjective data using proven methods to assess
the patient. The most common methods for collecting data are the patient interview, physical examination, and
observation.
 The patient interview is a deliberate or intended communication or
conversation with the patient. It is used to obtain information, identify
problems that concern the patient and/or the nurse, evaluate changes,
provide support, and educate the patient and family/caregivers.
The nurse will also conduct a head-to-toe nursing assessment addressing

each body system and noting any abnormalities, complaints, or
concerns. Observation requires the nurse to use all their senses (sight,
touch, smell, hearing) to learn about the patient.
 Organize and Validate Data:
 After collecting data, the nurse must organize and validate data and document
about the patient's health status. Validation is the process of verifying data to be
sure it is factual and accurate. Nurses must be careful to not come to conclusions
without adequate data to support their conclusion.
It is also necessary to understand the difference between inferences and cues.

Cues are signals the patient uses to alert the nurse about a concern or question or
objective data the nurse can observe or measure. Inferences are the nurse's
conclusion or interpretation based on cues.
 For example, the patient may complain about a painful incision two days post-
operatively, and the nurse may observe the incision site is red and feels hot. These
are cues. The nurse then makes an inference that the operative incision is infected.
Documenting Data:
 After data from the assessment is collected, organized, and validated, it must be
recorded. One thing I always tell nursing students and cannot stress enough to any
nurse is, "If you didn't document it, you didn't do it." While that may seem harsh,
from a legal standpoint, if a nurse is asked to verify care or treatment and there is
no supporting documentation, there is no way to prove the care occurred.
Thorough documentation is one of the best ways for everyone involved in patient
care to be aware of changes in the patient's status, and it helps promote effective
collaboration within the interdisciplinary team.
5 Common Challenges You Will Face During the Assessment Phase And How
To Overcome
 While all the nursing process steps are essential, without a thorough assessment, the other steps
of the nursing process are not as easy to follow through. Nurses must recognize barriers that
could impede the assessment phase and find ways to overcome them. The following are five
common challenges you may face during the assessment phase and some suggestions on how to
overcome them.
Challenge #1: Limited Time

 About the Challenge:
 There are days when nurses feel as though there aren’t enough hours to accomplish all the work
that needs to be done. When you are short-staffed or have several patients waiting for a nursing
assessment before you can initiate care, it can feel a bit overwhelming.
 How to Overcome:
 Even on the busiest of days, it is important for nurses to perform
thorough nursing assessments for all patients assigned to them. That
means it is necessary to learn to manage time efficiently. The first step in
overcoming limited time is to be familiar with the format or forms your
employer uses to record assessments.
For example, the Health Information Technology for Economic and

Clinical Health Act of 2009 advanced the adoption and use of electronic
health records. Nearly one hundred percent of hospitals use some type of
EHR. Electronic health records have helped improve workflow by
eliminating time spent pulling physical charts or documenting in paper
charts.
 Challenge #2: Interruptions
 It is not uncommon for interruptions to occur when nurses are performing assessments. While
some interruptions may be necessary, all are not. Interruptions during patient assessments can
delay care and could result in errors or omissions.
How to Overcome:
 The best way to overcome the challenge of interruptions during the assessment step of the
nursing process is to provide for privacy before you begin the assessment.
Whether you are working in triage, assessing a patient newly admitted to your floor, or in a
busy emergency room, it is possible to reduce interruption. Pull the privacy curtain closed if
you are in an area with more than one patient or several staff close by. Some facilities use "Do
Not Disturb" or "Room in Use" signs to provide privacy for nurses and patients.
 Challenge #3: Inexperience
 Every nurse knows the importance of a good nursing assessment. Newly graduated
nurses are less experienced than other nurses and may feel uneasy about performing a
nursing assessment alone. Additionally, if your facility changes its documentation
format or implements a new program for charting, and you've not yet used the program,
your inexperience could pose a challenge when doing an assessment.
How to Overcome:
 The only way to overcome inexperience is to become experienced. Nursing
assessments are typically classified as either a Complete Health Assessment or a
Problem-Focused Assessment. Know which type of assessment you need to perform.
 Gather basic equipment: gloves, thermometer, blood pressure cuff, stethoscope,
penlight, and watch. Establish a sense of trust and respect between the patient
and yourself.
No matter which type of assessment you perform, it should be systematic,

making sure you cover each body system. If you assess each body system and
make notes about what is normal/abnormal, you decrease the chances of
omissions in documentation. Remember, take your time, trust your instincts, and
if you need help, ask for it.
Challenge #4: Patient Anxiety
About the Challenge:
 Patient anxiety can create a significant challenge for nurses during a patient assessment. Anxiety
can hinder communication making it difficult to gather all the necessary data. If anxiety is bad
enough, it can cause changes in vital signs, which could be misinterpreted as something more
than an anxious reaction.
How to Overcome:
 Before beginning an assessment, take the time to make your patient comfortable. While you
may not have time for a long conversation or "get to know you" session, you can ease your
patient's anxiety by being calm and friendly.
 Some questions may make patients feel uncomfortable, especially teenagers. Allow them time to
answer your questions without feeling rushed. Verify their understanding by asking if they can
explain what you've discussed in their own words.
Remember, everyone gets nervous or anxious at times, and when we are sick, it can be worse. It's
nothing personal against you or your skills. Make everything about the patient.
 Challenge #5: Patients Not Being Forthcoming About Symptoms
 Whether it is fear of the unknown, embarrassment, or another reason, there are
times when patients may be apprehensive about sharing personal information.
 Lack of information or omission of details that the patient may think is irrelevant
may negatively impact the process of care planning. Therefore, while it is easy to
understand a patient's apprehension, it is crucial for nurses to gather as much
information as possible when performing a nursing assessment.
 It can be easy to feel frustrated if a patient is not forthcoming about symptoms
during an assessment. Keep in mind, being sick and needing medical care can be
frightening.
 The best way to get patients to talk to you is to be accepting of them, no
matter what. Be sure to tell your patient you are there for them and will
work with them to help them get better. When you say things like you will
"work with them," it lets your patient know you are going to do your part,
but you expect them to do theirs as well.
If you feel like your patient is withholding information, instead of making

an accusation, try to rephrase the question. Make your questions clear so
the patient knows what information you need.
Real-World Example Of The Assessment Phase
 The format for recording nursing assessment data may vary from
one facility to another. However, the information gathered for the
assessment is relatively similar. The following are examples of
content the nurse should include in the initial nursing assessment
phase of the nursing process.
Admission Notes
Date of Admission: 04/19/22 Time: 13.30

Transported By: J. Mock, LPN
Age: 54 yrs. 2 mos. Sex: M Height: 6’2” Weight: 268lbs 4oz
Attending Physician: Dr. Michael Coulvan
Date of Birth: 03/04/1968
Admitting Diagnosis: CHF, acute

Vital Signs on Admission: Temp 98.8, Resp. 20, Pulse 76, BP 136/80
Allergies: NKDA, no food allergies
Patient Demographics
 Patient Name: Jerold R. Collie
Address: 123 Blakely Lane, Clayton, MO. 1234
Phone: (318) 555-1234
Physical Assessment
• Neurological: Alert & Oriented x3; PERRLA, Unaided hearing; Bilateral hand grips equal; Bilateral foot
push equal; no evidence of tremors; denies tingling, burning, loss of consciousness, hallucinations,
disorientation, visual disturbances, or hx/o brain injury or stroke.
• Cardiovascular: Pulses present, regular, and strong: x2 upper extremities (Radial); present X2 lower
extremities (Pedal); heart rate regular, strong; capillary refill <3 second upper and lower extremities
• Respiratory Status: Respirations even, labored; Dyspnea on exertion; Lungs: Bilateral rales in lung bases;
Cough: Nonproductive; Oxygen: 2L per NC
• Gastrointestinal: Reports 10 lb weight gain in last two weeks. Continent of bowel; Last BM 4/19/22;
Laxatives: No, Enemas: No; Hx of Constipation: No
• Genitourinary: Continent of bladder; Uses urinal prn; urinal emptied of approximately 200 cc clear, amber
urine
• Integumentary: Skin is pink, warm, and dry; Mucous membranes pink and moist
• Musculoskeletal: Reports pain and stiffness in joints of hands mostly
in the a.m.; denies history of gout, arthritis, bursitis, or fractures;
Negative paralysis; Negative contractures, No congenital anomalies;
No prosthetic devices; Able to carry out most ADLs with minimal
assist but may require periods of rest r/t dyspnea with exertion; Uses
walker for ambulation.
Pain Assessment
 Location: Headache Intensity: Constant, throbbing Pain Scale: 5
Functional Status: Full weight-bearing; Ambulatory with 1 person assist; Client uses
walker occasionally; No supportive devices
Psychosocial: Client is alert, friendly, and answers questions readily; Comprehension:

rapid.
Marital Status: Divorced; Client lives alone in his own home; Has two adult children who
live nearby and visit frequently; Client reports he has several close friends who call or visit
often.
Prior Medical History: History of hypertension; Denies any other medical
issues prior to this admission.
Substance Use: Client reports previous substance abuse, methamphetamine was

his drug of choice. Client states he has been substance and alcohol-free for three
years.
Family Medical History: Paternal hx/o CHF, HTN, and Lung Ca. Maternal hx/o
DM, and HTN.
*In addition to the information the nurse will gather during her assessment, the
assessment phase of the nursing process includes gathering objective data such as
copies of laboratory or diagnostic testing. If the facility uses electronic health
records, as most do, this information will probably already be uploaded to the
patient’s electronic chart. It is, however, the nurse’s responsibility to gather and
verify all data is available.
Frequently Asked Questions About The Assessment Phase
 1. Why Is Assessment The First Step Of The Nursing Process?

The assessment phase of the nursing process lays the foundation upon which
all other nursing process steps build. The information gathered during the
nursing assessment tells the nurse about the patient’s history, current
complaints, medications, and any other pertinent information that may impact
care planning. Without a thorough, proper patient assessment, it is impossible
to develop a patient-specific care plan.
 2. How Is The Data For Assessment Obtained?
Nurses collect data during the assessment phase by communicating with the
patient, spouse, and caregivers, reading patient records, nursing observation, and
collecting measurable data such as vital signs.
3. What Subjective Data Is Collected When Assessing A Patient?

Subjective data is any information the nurse collects through communication. A
few examples of subjective data include the reason for the patient’s visit to the
doctor, patient or family medical history, medications the patient is taking, and
any symptoms such as chills, aches, or pain.
 4. What Objective Data Is Collected When Assessing A Patient?
Objective data is any measurable information obtained from sources other than
the patient. For example, the patient’s height, weight, vital signs, and laboratory
or diagnostic test results are objective data collected during a patient assessment.
5. How Do Nurses Collect Verbal Data?

Nurses collect verbal data by talking to patients, their family members (when
appropriate), and other members of the healthcare team. Subjective matter is
usually often the result of verbal communication during the patient interview.
 6. How Do Nurses Collect Nonverbal Data?
Nonverbal data is collected during the assessment phase of the nursing process by
observing the patient's body language, reading patient charts, or medical test results.
For example, the patient may not offer a verbal report of pain, but the nurse may
observe him clutching or guarding his side, which could indicate pain.
The nurse can use the nonverbal data to form assessment questions as a way of
following up with what she has observed or read.
7. What Are The Sources From Where Data Is Collected?

The primary source of data collection during the nursing assessment is the patient.
Other sources include family, friends, caregivers, and other members of the
healthcare team. Data are also collected from laboratory or diagnostic reports, the
patient’s medical records, and the nurse’s observations.
 8. What Does Tertiary Source Of Data Mean?
 Tertiary data are data gathered from sources such as the patient's chart, lab, or x-ray reports. Nurses may
also use tertiary sources such as diagnostic manuals or textbooks to verify or compare information.
9. How Do Nurses Verify Whether The Collected Data Is Accurate Or Not?

 Nurses can use a few methods to verify the accuracy of data collected during the assessment phase of the
nursing process.
A few ways to verify data is to clarify information with the patient by asking additional questions,
compare objective and subjective data to see if there are any discrepancies, recheck data by repeating the
assessment, and verifying data with another nurse or healthcare team member.
One example of verifying data is to perform repeat vital sign check. For instance, if Mr. Jones has a blood
pressure reading of 220/100 but has no history of hypertension, the nurse should retake his blood pressure
to validate its accuracy. If the nurse feels it is necessary, they may use different equipment or ask
someone else to perform the vital sign check to check for accuracy.
 10. What Methods Do Nurses Use To Collect Data?
The primary methods nurses use to collect data are observation, patient interviews,
and head-to-toe assessments.
11. What Tools And Equipment Are Used To Collect Data?

Nurses use various tools and equipment to help gather data about patients. A few
examples of tools and equipment nurses use include a stethoscope, blood pressure
cuff, thermometer, pulse oximeter, and scales. You may need a glucometer and lancets
to check blood sugar, as well.
STEP #2: DIAGNOSIS PHASE
What Is The Diagnosis Phase?
Diagnosis is the second phase of the nursing process. It is also
designated by the American Nurses Association as the second Standard
of Practice. The standard is defined by the ANA stating, "The
registered nurse’s analysis of assessment data to determine actual or
potential diagnoses, problems, and issues.” The nursing diagnosis
reflects the nurse’s clinical judgment about a patient’s response to
potential or actual health issues or needs.
What Are The Top 3 Reasons Why The Diagnosis Phase Is Important?
 Before a plan of care can be established, nurses must determine which
nursing diagnosis/diagnoses apply to their patients. The following are a few
reasons why the diagnosis phase of the nursing process is important.
1. The diagnosis phase of the nursing process helps nurses view the patient
from a holistic perspective.
2. Using a nursing diagnosis can lead to higher quality nursing care and
improved patient safety, as care is based upon the needs outlined in the
diagnosis.
3. The diagnosis phase helps increase the nurse’s awareness and can
strengthen their professional role.
What Are The 5 Main Objectives Of The Diagnosis Phase?
 In the diagnosis phase, the nurse follows a set of objectives that end with
developing the nursing diagnosis/diagnoses used to establish patient care.
These are the main objectives of the diagnosis phase:
1. Identify and Define the Problem(s):

 The nurse must identify what problem the patient is experiencing related to
the medical diagnosis.
2. Identify Risk Factors:

 Any situation or problem that could result because of the patient’s medical
diagnosis is a risk factor for a nursing diagnosis and must be addressed.
 3. Analyze Data:
 All data gathered during the assessment phase of the nursing process must be compiled,
validated, and analyzed to support an appropriate nursing diagnosis.
4. Develop a theory/hypothesis:
 Nursing theories involve an organized framework of concepts and purposes that guide
nursing practices. A nurse’s theory is their unique perspective about the patient’s status
and measures needed to improve the patient’s outcome.
5. Establish a nursing diagnosis:

 After identifying problems and risk factors, analyzing data, and developing a nursing
theory, the nurse can then establish a nursing diagnosis or diagnoses which is used to
establish a nursing care plan.
What Skills Are Required For The Diagnosis Phase?
 Nurses will utilize several skills in the diagnosis phase of the

nursing process steps. Critical thinking, problem-solving, and
communication skills are necessary to work in this phase. Nurses
must also demonstrate the ability to prioritize patient needs.
What Exactly Does The Diagnosis Phase Involve?
 The diagnosis phase of the nursing process involves three main steps: data analysis,
identification of the patient’s health problems, risks, and strengths, and formation of diagnostic
statements.
• Data Analysis involves the nurse clustering cues, comparing patient data against standards, and
identifying inconsistencies or gaps in the data.
• After data analysis, the nurse will work with the client to identify actual, risk, and possible
diagnoses. In this step, the nurse will determine if an identified problem classifies as a nursing
diagnosis, medical diagnosis, or collaborative diagnosis/problem. It is important to involve the
patient in this step whenever possible, to identify the client's resources, coping abilities, and
strengths.
 • The last step of the diagnosis phase involves creating a nursing
diagnosis. The nursing diagnosis may have up to three components:
a NANDA-I approved nursing diagnosis, a diagnosis
statement which defines the cause of the diagnosis, and an
as evidenced by statement that uses patient-specific data to justify
the diagnosis and diagnostic statement.
5 Common Challenges You Will Face During The Diagnosis
Phase And How To Overcome
 The nursing diagnosis is different from a medical diagnosis. It

requires careful consideration of the patient’s individual problems,
situation, and needs to develop appropriate nursing diagnoses. Here
are a few examples of challenges that may occur during the
diagnosis phase of the nursing process and some suggestions on
how to overcome them.
Challenge #1: Creating a Nursing Diagnosis Is Often a
Complex Process

 Although there are resources and guidelines to help nurses develop nursing diagnoses, the process can be
complex. Before nurses can create a nursing diagnosis, they must interview and assess the patient and
review data, which can be time-consuming.
How to Overcome:
 While you may not overcome the complexities of creating nursing diagnoses, it is possible to make the
process easier.
For example, be sure to review all objective data, including baseline vitals, laboratory or diagnostic test
results, and subjective data. Make sure the patient's medical history is accurate and find answers to any
questions not yet answered. The more information you have to work with, the easier it becomes to develop
diagnoses based on that data.
Challenge #2: Nurses May Interpret Data Differently

 Some data are taken at face value, such as laboratory or diagnostic test results or vital signs, which
are measurable. Subjective data is data reported by the patient. It is information given to the nurse
by the patient based on the patient’s perception of what he is feeling. Despite efforts to appreciate
the patient’s perception, nurses sometimes interpret data differently. When this happens, it can create
a challenge when developing nursing diagnoses for the nursing care plan.
How to Overcome:
 It is essential for nurses to have a clear understanding of which data is objective or subjective. Once
the differences in data are realized, nurses must be careful to not rely upon only one piece of data or
their own perception of data to create a nursing diagnosis. Instead, establishing nursing diagnoses
should be a collaborative effort among the nursing care team. Nurses assigned to a patient’s care
should discuss their perception of data and make informed decisions based on all data.
Challenge #3: Insufficient Data to Support a Nursing Diagnosis

 Nurses must review all available data, including but not limited to subjective and objective findings,
lab and diagnostic test results, and narrative notes from the patient interview before a nursing
diagnosis can be made. If the nurse does not obtain enough data during the assessment, it will be
difficult to establish appropriate nursing diagnoses.
How to Overcome:
 The best way to overcome the challenge of insufficient data is to perform a thorough assessment,
patient and/or family interview, and make sure all results from any tests are readily available for
review.
If you have reached the diagnosis phase of the nursing process and find you do not have enough
data, go back to the sources of information and gather data. You may find that you need to reassess
the patient or ask additional questions.
Challenge #4: Lack of Communication Between Nursing Staff

 Although patients are assigned a primary nurse, nursing is a team effort that requires collaboration. When
there is a lack of communication between nursing team members, information may be inadvertently
omitted from notes or reports. This failure in communication makes getting a complete view of the
patient's status difficult, resulting in challenges in developing appropriate nursing diagnoses.
How to Overcome:
 Nurses must be alert and responsive to patients and one another. End of shift report is an excellent way for
nurses to communicate changes in a patient's status. Nurses should make notes of anything pertinent before
handing off care to the next shift nurse and clearly communicate concerns about the patient's progress or
lack thereof.
 When the lack of communication is resolved, nurses can compare information to use when establishing
nursing diagnoses, ensuring the patient gets the best care possible.
Challenge #5: Deciding the Type of Nursing Diagnose to Use

 There are four main types of nursing diagnoses: Problem-focused, Risk,
Health Promotion, and Syndrome.
When nurses get to the diagnosis phase of the nursing process, they must
determine which type or types of diagnoses are relevant to their patients.
While experienced nurses may find it easier to decide which type of
diagnosis to use, new or less experienced nurses may find it challenging.
 Additionally, some healthcare facilities prefer nurses to use a specific type
of diagnosis, which can be frustrating, especially if the nurse feels a
different type of nursing diagnosis is more appropriate.
 Overcoming the challenge of choosing the right type of nursing
diagnosis requires understanding when each type is most
appropriate. If the nurse has sufficient data from the assessment
phase, they can then identify potential diagnoses and determine
which type of diagnosis to use.
The following are the four types of nursing diagnoses and examples of each.
• Problem-Focused Nursing Diagnoses focus on a specific problem the patient is

experiencing. This type of diagnosis has three components: a nursing diagnosis,
related factors or diagnosis statement, and defining characteristics or the as evidenced
by statement.
For example, the patient with chronic obstructive pulmonary disease (COPD) could
have a problem-focused nursing diagnosis of "Ineffective Breathing Pattern related to
decreased lung expansion as evidenced by dyspnea and ineffective cough."
Risk Nursing Diagnoses identify potential problems or risks the patient may
experience because of his medical diagnosis. A risk nursing diagnosis typically has
two components, the diagnosis, and risk factors. The patient with COPD may have a
risk diagnosis of "Risk for Ineffective Airway Clearance related to decreased lung
capacity."
• Health Promotion Nursing Diagnoses (a.k.a. Wellness Nursing Diagnosis)
is based on the nurse's clinical judgment about the patient's desire and
motivation to increase his well-being. These diagnoses focus on the client's
transition from one level of wellness to a higher level of wellness.
Health promotion nursing diagnoses are usually one-part statements or

include only a diagnostic statement. The COPD patient's Health Promotion
Nursing Diagnosis may state "Readiness for Enhanced Wellness."
 • Syndrome Nursing Diagnoses are clinical judgments related to a
cluster of risk nursing diagnoses predicted to occur because of a
particular event or situation. The syndrome nursing diagnosis is also
written as a one-part statement. For example, the COPD patient may
have a syndrome diagnosis of “Ineffective Airway Clearance,
Impaired Gas Exchange, Ineffective Breathing Pattern.”
Real-World Example Of The Diagnosis Phase
 After reviewing the data collected in the assessment phase of the nursing process,
the nurse determines which type of diagnosis is appropriate and moves to the
planning phase. In the case of Mr. Collie, the nurse chooses a problem-focused
nursing diagnosis and a risk nursing diagnosis.
Nursing Diagnoses
 • Decreased Cardiac Output r/t impaired contractility and increased preload and
afterload AEB irregular heartrate of 118, fatigue, and dyspnea on exertion
(Problem-focused)
• Risk for Impaired Skin Integrity r/t edema, decreased tissue perfusion, and
decreased activity. (Risk)
Frequently Asked Questions About The Diagnosis Phase
 1. What Is The Difference Between Nursing Diagnosis And Medical Diagnosis?

 Although they share similarities, nursing and medical diagnoses are different. The nursing
diagnosis is used by a nurse to identify a patient’s actual or potential risk(s), wellness, or
responses to a health problem, condition, or state. A medical diagnosis is used by physicians
to determine or identify a specific condition, disease, or pathologic state.
 2. What Is The Meaning Of NANDA-I?
 NANDA-I stands for North American Nursing Diagnosis Association International.
NANDA-I is a professional organization that researches, develops, disseminates, and refines
nursing diagnosis terminology. The organization was formed as NANDA in 1982, it was
renamed NANDA-I in 2002 because of its increased worldwide membership.
3. What Are The Components Of A Nursing Diagnosis?
 Each nursing diagnosis is made up of four main components: problem and
its definition, etiology, risk factors, and defining characteristics.
4. What Is The Purpose Of Establishing A Nursing Diagnosis?

 The primary purpose of establishing a nursing diagnosis is to communicate
the healthcare needs of the patient among members of the healthcare team
and within the delivery system. The nursing diagnosis allows nurses to
facilitate individualized care for the patient and family and strengthens the
profession.
 5. Why Is It Important to Form an Accurate Nursing Diagnosis?
 The nursing diagnosis serves as the basis for selecting nursing interventions, which have a
significant impact on patient outcomes. If an accurate nursing diagnosis is not chosen, the plan
of care and subsequent nursing interventions may not address the patient’s issues appropriately
resulting in negative patient outcomes.
6. How Do Nurses Rank Nursing Diagnoses?

 Nursing diagnoses are ranked in order of importance. Immediate life-threatening problems or
issues related to survival are given the highest priority.
7. Can Two Patients with the Same Medical Diagnosis Have Different Nursing Diagnoses?
 Nursing diagnoses focus on the patient’s response to health conditions, and patients often
respond differently. Therefore, it is not uncommon for patients with the same medical
diagnosis to have different nursing diagnoses.
STEP #3: PLANNING PHASE
 What Is The Planning Phase?

The planning phase of the nursing process is the stage where
nursing care plans that outline goals and outcomes are
created. The goals and outcomes formulated during this
phase directly impact patient care and are based on evidence-
based nursing practices.
 What Are The Top 3 Reasons Why The Planning Phase Is Important?
The planning phase of the nursing process is essential in promoting high-
quality patient care. It is considered the framework upon which scientific
nursing practice is based. The following are three of the top reasons why the
planning phase is so important.
1. Care planning provides direction for personalized patient care based on the
client's unique needs.
2. The planning phase enhances communication between patients, nurses, and
other members of the healthcare team.
3. Planning encourages continuity of care across the healthcare continuum and
promotes positive patient outcomes.
What Are The 5 Main Objectives Of The Planning Phase?
 The American Nurses Association's Standards of Clinical Nursing Practice identifies

planning as one of the essential principles for promoting the delivery of competent
nursing care. The planning phase of the nursing process has five main objectives, all of
which focus on nursing interventions to promote positive patient outcomes. The
following are the main objectives of the planning phase.
1. Establish Priorities:
 The nurse reviews the nursing diagnoses and prioritizes them according to
physiological and psychological importance. This step helps the nurse organize the
patient’s nursing diagnoses into a format that promotes effective planning.
2. Develop SMART goals:
 This objective of the planning phase of the nursing process involves setting
goals related to each diagnosis. Goal setting helps to provide guidelines for
nursing interventions and establishes criteria by which the care plan's
effectiveness is evaluated.
Remember the acronym SMART when developing goals. SMART goals are
Specific, Measurable, Relevant, and Time-bound.
3. Establish Expected Outcomes:

 After goals are established, the nurse can identify expected outcomes based on
each goal. Outcomes should be realistic, mutually desired by the patient and
nurse, and attainable within a designated amount of time.
4. Identify Interventions:
 After goals are agreed upon and established, the nurse then implements
decision-making skills to select nursing interventions that are relevant to the
nursing diagnoses. Interventions are prioritized in order of planned
implementation.
5. Document the Care Plan:

 After priorities, goals, outcomes, and interventions are established, the nurse
must document the care plan.
Documentation of the care plan includes nursing orders which communicate

the interventions the nursing staff will implement for the client. Nursing orders
must be well-written and should include the order date, which action will be
performed, a detailed description, the time frame in which the intervention will
be performed, and the nurse's signature.
What Skills Are Required For The Planning Phase?
 Nurses utilize many of the same skills for each of the nursing process
steps. In the planning phase, nurses must have strong communication
skills, time management and organizational skills, and a willingness to
work collaboratively with the patient and interdisciplinary team.
Nurses must have strong critical thinking skills, as they must weigh the
risks and consequences of each intervention.
What Exactly Does The Planning Phase Involve?
The planning phase of the nursing process is when nurses formulate goals and
outcomes that impact patient care. This step involves prioritizing patient needs,
identifying expected outcomes, establishing nursing interventions, and
identifying patient-centered goals.
In the planning phase, nurses identify goals and outcomes for patient care based
on evidence-based practice guidelines. Once objectives of planning are met, the
nurse creates a written plan of care, or care plan.
The care plan is a written guide organizing data about the patient's care into a
formal statement of strategies or interventions the nurse will enact to help the
patient achieve optimal outcomes.
5 Common Challenges You Will Face During
The Planning Phase And How To Overcome
It is normal to face challenges, no matter which phase of patient care
you are involved with. The planning phase can feel a bit tricky because
nurses need to be careful to develop plans considering the individuality
of the patient. The following are a few examples of challenges you
could phase when you begin planning patient care.
Challenge #1: Not Knowing How to Format the Care Plan
 There are different formats for creating a care plan. If nurses do not know the format their
facility uses, it can be easy to overlook components of the plan, which may impact the
delivery of care and patient outcomes.
How to Overcome:
 Not knowing how to format a care plan is probably one of the easiest challenges to
overcome in the planning phase. With the implementation of electronic health records and
programs that help nurses choose nursing diagnoses and interventions, creating care plans
has become easier.
As a nurse creating a care plan, your job is to make sure all relevant information is
included in the plan. The nursing diagnosis, interventions and expected outcomes, time
frames in which outcomes should be accomplished, and a place to document evaluations
should all be included.
Challenge #2: Not Establishing Goals and Expected Outcomes
 Have you ever heard the saying, "Failure to plan is planning to fail"? That principle applies to everything
in life, including patient care. No care plan is complete without clear goals and outcome identification. If
there are no goals or an insufficient number of goals relevant to the nursing diagnoses, deciding on
interventions is impossible.
How to Overcome:
 The nursing care plan should always be patient-centered and individualized. Goals and outcomes should
be tailored to meet each patient's needs and should be considerate of the patient's cultural beliefs and
values.
 Nurses use the nursing care plan as a road map that all members of the nursing team use to help the
patient reach goals. It is vital that nurses establish goals that are attainable and relevant to the patient's
specific needs.
In the planning phase of the nursing process, the nurse should establish short-term and long-term goals
and determine the outcome associated with achieving those goals. Establishing goals and outcomes is
vital to this step in the nursing process. Therefore, nurses should take the time to consider each goal and
outcome carefully and discuss the plan with the patient and healthcare team.
Challenge #3: Unrealistic Goals

 While it is okay to be optimistic about a patient’s ability to achieve goals, it is
essential for nurses to be realistic about what their patients can or cannot do.
If goals are unrealistic, patients can quickly become frustrated. Frustration
often leads to noncompliance, which can negatively affect patient outcomes.
Challenge #3: Unrealistic Goals
How to Overcome:
 After carefully determining nursing diagnoses, the nurse must determine which
goals the patient can achieve realistically. Realistic goals are specific and well-
defined, measurable, achievable, relevant to the patient's status and needs, and
achievable within a specific timeframe.
To overcome the challenge of unrealistic goals, identify what is essential in helping

the patient achieve optimal outcomes. Discuss goals with the patient, family, care
providers, and nurse manager. Once realistic goals are identified, offer support and
encouragement to the patient. The nurse should continually monitor and assess the
patient's progress toward meeting goals.
 Challenge #4: Limited Patient Input
 Although nurses can create nursing care plans independent of patient input,
excluding patients from plans about their care may lead to distrust or confusion.
If a patient feels he cannot communicate with nurses or his opinion is not
valued, it can result in noncompliance with the care plan and negatively impact
the patient’s outcome.
 Challenge #4: Limited Patient Input
 When patients are involved in their care, the processes of planning and
implementation seem to flow easier.
Nurses can overcome the challenge of limited patient output by promoting a

comfortable, trusting nurse-patient relationship which encourages patient
participation. Ask the patient about their health goals and what limits they feel
may affect their ability to reach goals. Offer suggestions about desired goals and
expected outcomes and explain why they are relevant to the patient's health and
long-term well-being.
Challenge #5 Being Unsure of Appropriate Time Frames to Meet
Expected Outcomes/Goals

 It is possible for nurses to create realistic goals and expected outcomes in
the care plan but to set unrealistic time frames in which the patient is
expected to meet those goals.
One reason this challenge occurs is nurses sometimes fail to plan care
based on an individual patient’s abilities. Instead, they establish goals
based on their perception of what any patient with the same diagnosis may
be capable of achieving.
Challenge #5 Being Unsure of Appropriate Time Frames to Meet
Expected Outcomes/Goals
 When working through the planning phase of the nursing process, nurses
must consider patients as individuals with specific needs and abilities. The
nurse should specify a time frame for achieving goals that is reasonable
and that does not create undue stress or worry for the patient.
When discussing the care plan with the patient, it is important to explain
each goal to the patient. Include education about why there is an
anticipated time for accomplishing goals and what each person's
responsibilities are to help make achieving the goals possible.
Real-World Example Of The Planning
Phase
 Once the nursing diagnosis or diagnoses are established, the nurse completes
the planning phase of the nursing process by determining patient goals and
expected outcomes and establishing which nursing interventions to initiate.
The following are goals and expected outcomes for Mr. Collie based on the
nursing diagnoses of Decreased Cardiac Output and Risk for Impaired Skin
Integrity.
 Decreased Cardiac Output
Goals and Expected Outcomes
1. The client will verbalize understanding of activities and lifestyle changes focused on reducing
cardiac workload.
2. The client will demonstrate adequate cardiac output AEB vital signs within normal limits.
3. The client will report decreased episodes of dyspnea.
 Nursing Interventions
1. Monitor vital signs.
2. Palpate peripheral pulses.
3. Assess for signs of edema.
4. Monitor for signs of pallor or cyanosis.
Risk for Impaired Skin Integrity

 Goals and Expected Outcomes
 1. Maintain skin integrity.
2. The client will verbalize understanding of techniques/behaviors to prevent skin breakdown
by end of shift.
 Nursing Interventions
1. Inspect skin, noting areas of altered circulation, bony
prominences, and/or signs of emaciation.
2. Encourage frequent position changes
3. Provide alternating pressure mattress, heel protectors, and elbow
protectors
Frequently Asked Questions About The Planning Phase
 1. What Are The Components Of A Care Plan?

 There are four main components of a nursing care plan: Client Assessment, including
medical and diagnostic reports, Nursing Diagnosis, Desired Outcomes/Goals, Nursing
Interventions with evidence-based rationale, and Evaluation.
2. How To Write A Nursing Care Plan?
 The best way to write a nursing care plan is to include information associated with the
nursing process steps.
• Assess the client: Review all relevant data, medical history, vital signs and assessment
data, physical, emotional, spiritual, ad psychosocial needs, identify areas where
improvement is needed, and establish risk factors.
• Identify Nursing Diagnoses: A nursing diagnosis is an actual or potential health problem
that nurses can address without physician intervention. A few examples include risk for
falls, risk for compromised skin integrity, and risk for dehydration.
 • Set Goals: Setting goals requires establishing desired outcomes and
identifying measures by which the patient will achieve them. Although there
may be situations where it is not possible, it is ideal to set goals with the
patient when they are able.
• Implement Nursing Interventions: Nursing interventions are actions taken
by the nurse to help patients achieve goals and meet desired outcomes. Nursing
interventions include initiating fall precautions, administering medications,
and assessing the patient’s pain level.
• Evaluate effectiveness of the plan and change or update, as needed or
indicated.
The next two FAQs about the planning phase are related to setting goals. Goals
are statements of purpose describing an objective to be accomplished. All
goals in the nursing care plan should be client-centered and measurable.
 Each goal should focus on the problem, measures to resolve the problem, and
rehabilitation. The time frame given to accomplish goals in the care plan varies,
depending on the setting where patient care is provided.
A tip I always share with students is, if you are not sure how to write a goal, try
converting the nursing diagnosis into a positive statement of action.
3. How To Set Goals For Short-Term Nursing Care Plans?

 A short-term goal in nursing care plans is a goal focused on demonstrating a change in
behavior. Short-term goals can be completed in as little as a few minutes or up to a few
days. The nurse should consider what behavior the patient can most easily exhibit or
identify to show understanding of goals and attempts to achieve goals.
3. How To Set Goals For Short-Term Nursing Care Plans?
For example, let’s consider the following nursing diagnosis and determine a short-
term goal.
“Ineffective airway clearance related to decreased energy, fatigue, and pneumonia
as evidenced by dyspnea, decreased breath sounds over affected lung, and
ineffective cough.”
Short-term goal example: “Patient will identify and demonstrate behaviors to

achieve airway clearance within eight hours of nursing intervention as evidenced
by respiratory rate not greater than sixteen breaths per minute, and absence of
dyspnea and cyanosis.”
 4. How To Set Goals For Long-Term Nursing Care Plans?
 Long-term goals are the desired outcome related to accomplishing one or
more short-term goals for an extended period. In some cases, long-term goals
can take weeks, months, or even years, to achieve.
Sample nursing diagnosis: “Situational low self-esteem related to change in

functional abilities due to loss of body part as evidenced by preoccupation
with missing limb, not looking at or touching stump following right above the
knee amputation.”
 Long-term goal examples: “Client will demonstrate adaptation to physical
changes and acceptance of self as an amputee within ninety days following
surgery; Client will develop plans for adapting to role modification and
demonstrate positive self-esteem within six months.”
 5. Are There Different Types of Planning in the Nursing Process?
 Planning occurs in three stages: initial, ongoing, and discharge. Initial
planning occurs when the nurse performing the admission assessment
develops a preliminary plan of care. Ongoing planning is the process
of updating the patient’s plan of care as new information is collected
and evaluated. Discharge planning begins at admission and involves
the anticipation of the client’s needs and plans to meet those needs
after discharge from care.
6. Should Patients Be Involved in the Planning Phase of the Nursing
Process?
 When possible, the patient should be included in all phases of the
nursing process. The patient is the best source of data, the person
being treated, and usually the most reliable source of information used
to determine the patient’s strengths, weaknesses, and likelihood of
compliance with a plan of care.
STEP #4: IMPLEMENTATION PHASE
What Is The Implementation Phase?

The fourth phase of the nursing process is the
implementation phase. This phase is when nurses initiate
the interventions established during the planning phase.
 What Are The Top 3 Reasons Why The Implementation Phase Is
Important?
After the nursing assessment is performed, nursing diagnoses are established, and
a care plan is developed, the plan must be initiated. All phases of the nursing
process are essential. The following are three of the top reasons why the
implementation phase is so important.
1. Implementation of the nursing process is significant because it involves action

on the nurse's part to promote positive patient outcomes. Conversely, if the care
plan is not implemented, there is a lack of nursing care, negatively impacting
patient outcomes.
2. When the nursing care plan is implemented (implementation phase), nurses can
begin to gauge patient responses to interventions.
3. Implementation supports continuity of care. Care begins from the first patient
encounter and continues until discharge.
What Are The 5 Main Objectives Of The Implementation Phase?
 The implementation phase of the nursing process is an ongoing process in patient care. From
the time a plan is established, the implementation process continues in a cycle which includes
the five objectives below.
1. Ongoing Assessment:
 The nursing care plan is developed based on data from the initial nursing assessment.
However, because a patient's condition can change quickly or nurses may obtain new data,
ongoing assessments are necessary to validate the need for proposed interventions. Ongoing
observations and assessments provide information supporting adaptations of the nursing care
plan to promote improved, individualized care.
2. Establishing Priorities:
 Utilizing data from initial and going assessments, the nurse then establishes priorities for
implementing care. Prioritization is based upon which problems are considered most
important by the nurse, patient, family/significant others, previously scheduled
tests/treatments (diagnostic tests, surgery, therapy), and available resources.
 3. Allocating Resources:
 Before implementing nursing interventions, the nurse must review proposed
interventions and determine the skills and knowledge level required to safely
and effectively implement them. For example, the nurse will consider if the
patient can independently perform an activity, if a family member may assist, or
if the activity requires assistance from a healthcare professional.
Although some interventions require the skills and knowledge of a registered

nurse, others are less complex and may be delegated to licensed
practical/vocational nurses or assistive personnel. The nurse allocates personnel
resources by determining the needs of the client, the type of personnel who are
available, and facility protocol for care.
4. Initiating Nursing Interventions:
 After verifying priorities and determining resources, the nurse can initiate nursing
interventions. Interventions are determined by the cause of the problem and often vary among
patients with similar nursing diagnoses depending on expected outcomes for each patient.
When initiating nursing interventions, the patient's preference and developmental level should
be considered. Additionally, nurses must review the physician's orders which may impact
nursing interventions by imposing restrictions on specific factors such as the patient's allowed
activity level or diet.
5. Documenting Interventions and Patient Response:

 Nurses are legally obligated to document all interventions and any observations concerning the
patient's response to those interventions. Documentation may be done on checklists, flow
sheets, or in narrative form. Any verbal communication between the patient and nurse or
among the healthcare team related to interventions and patient responses should be recorded, as
well.
What Skills Are Required For The Implementation Phase?
Like the other nursing process steps, the implementation phase requires broad clinical
knowledge, critical thinking and analysis skills, and strong judgment.
Whether a nurse is caring for one patient, or several patients, careful planning and time
management skills are essential in this phase. Nurses must have psychomotor,
interpersonal, and cognitive skills as these serve as competencies through which high-
quality nursing care is delivered.
Psychomotor skills are necessary to safely perform nursing activities such as handling
medical equipment competently.
Interpersonal skills help nurses establish therapeutic nurse-patient relationships and

promote interdisciplinary collaboration.
Cognitive skills are necessary to help the nurse understand the rationale for proposed
interventions and make appropriate observations.
What Exactly Does The Implementation Phase Involve?
Implementation involves a focus on accomplishing predetermined goals and
continuous progress toward achieving desired outcomes. This phase of the
nursing process involves prioritizing nursing interventions, assessing patient
safety during nursing interventions, delegating interventions when
appropriate, and documenting all interventions performed.
5 Common Challenges You Will Face During The Implementation Phase And How To
Overcome
 Nursing interventions vary depending on the patient and the setting where care is
provided. The following are examples of common challenges nurses face during the
implementation phase of the nursing process and suggestions for how to overcome
them.
Challenge #1: Lack of Clinical Experience

 Even when goals and desired outcomes are clearly defined, inexperienced nurses may
find implementing nursing interventions challenging. Inexperience may occur because
the nurse is newly graduated or if a nurse is transferred to a department where they
have never worked.
 Challenge #1: Lack of Clinical Experience
How to Overcome:
 While the most effective way to overcome a lack of clinical experience is to
work as much as you can and gain experience, patient care cannot wait for us to
feel comfortable performing unfamiliar tasks.
When nurses face challenges implementing patient care because of inexperience,

the best way to overcome it is to speak up and ask for help. As a nursing
instructor, I always encouraged my students to ask questions about everything.
The only bad question is the one you do not ask. Nurse leaders, supervisors, and
administrators appreciate nurses who readily admit when they need help or
guidance.
 Challenge #2: Patient Noncompliance
 Noncompliance is recognized by NANDA-I as a nursing diagnosis. It is defined as “the
behavior of a patient or caregiver that does not correspond with the therapeutic plan agreed
upon by the individual, family or guardian, and healthcare provider.” Noncompliance can
negatively impact patient outcomes, reduce the patient’s quality of life, and result in
increased healthcare costs.
How to Overcome:
 One of the best ways to prevent or stop patient noncompliance is to involve the patient in all
aspects of care planning.
Nurses should ensure the patient is educated about their illness, plans to manage the illness,
and expected outcomes of therapies. Education should also include information about how
noncompliance may negatively affect the patient's outcome. The patient's understanding of
all education should be verified, and if the nurse is unsure the patient clearly understands,
teaching should be repeated.
 Challenge #3: Psychosocial Factors
 Psychosocial factors can impact all aspects of patient care. For example, if there is a
presence of domestic abuse or violence, the patient may be afraid to discuss important
issues related to care, which could result in misunderstanding established goals.
How to Overcome:
 Psychosocial factors may seem a little tricky to navigate. However, if they become a
factor affecting the implementation of the nursing process steps, nurses must find a way
to try and address the issues.
For instance, if the nurse suspects a patient is afraid to discuss certain issues in the
presence of others, the nurse should ask for privacy while talking to the patient. By
doing so, the nurse offers the patient the opportunity to speak openly without fear of
retaliation by an abuser. Then the nurse can discuss options for care with the patient and
how to proceed moving forward.
 Challenge #4: Nursing Care Plan Does Not Reflect Appropriate Care for the
Nursing Diagnoses
 Every step of the nursing process builds upon the previous step. Nurses must perform a
thorough assessment and collect sufficient data before making nursing diagnoses. After
a nursing diagnosis is established, interventions are planned to help resolve the issue(s)
the patient is experiencing. If the planned interventions do not align appropriately with
the care expected for a nursing diagnosis, implementing the care plan properly cannot
occur.
How to Overcome:
 It is vital for nurses to handle each phase of the nursing process with deliberate care
and appropriate actions. Nursing care plans should be evaluated by the nursing team to
ensure that the patient’s needs are addressed, and planned interventions are relevant to
the nursing diagnosis/diagnoses.
 Challenge #5: Nursing Shortage
 The World Health Organization estimates a shortage of more than four million
nurses in the United States. No matter how well-written a nursing care plan is, if
there is not enough staff to carry out the nursing interventions, the plan cannot be
successfully implemented.
How to Overcome:
 While it is understandable that one nurse cannot remedy the nursing shortage, there
are things all nurses can do to help relieve the impact the shortage causes.
Real-World Example Of The Implementation Phase
 Implementation of the nursing care plan involves educating the patient and helping
him achieve goals and expected outcomes. It also involves putting the planned nursing
interventions into action. To implement the care plan, the nurse will establish
priorities, delegate tasks to appropriate staff, initiate interventions, and document
interventions and the patient’s response.
Nursing documentation should be accurate and relevant to the patient. Use appropriate
nursing language and facility-approved abbreviations. In the case of Mr. Collie, the
nurse's documentation may look like the following narrative.
 04/19/22 @ 1430: Discussed plan of care with client and son who was present in
the room, including educating about goals and expected outcomes. The client
verbalizes understanding of the importance of lifestyle and activity changes to
reduce cardiac workload, the need for vital signs to be within normal limits, and
measures to decrease episodes of dyspnea, and safety precautions. The client also
verbalizes understanding of the risk for impaired skin integrity and verbally recalls
skin integrity is at risk due to "bad circulation and swelling." The client voices
understanding that frequent position changes and keeping the skin clean and dry
will decrease the likelihood of skin breakdown. Assessed peripheral pulses, which
are present and strong bilaterally in upper and lower extremities X2, 2+ pitting
edema noted in bilateral lower extremities. Skin remains intact, pink, warm, and
dry, no signs of redness or pallor. Heel and elbow protectors applied. Alternating
pressure mattress in place and operational. ------------D. Leonard, RN
Frequently Asked Questions About The Implementation Phase
 1. What Are The Steps In The Process Of Implementing A Nursing
Plan?
 The first step in the process of implementing a nursing care plan is to
determine what, how, and when an intervention should be performed.
Once you know the what, how, and when, you can determine if the
task can be delegated and to whom.
 2. What Are The 3 Types Of Interventions That Are Implemented?
 The three types of interventions implemented in the nursing process are independent,
dependent, and interdependent.
• Independent interventions are actions nurses can perform on their own and do not
require assistance from other team members. For example, routine tasks such as monitoring
vital signs or assessing the patient's pain level are independent nursing interventions.
• Dependent interventions require instructions or input from the physician. For instance, if
the patient needs a new medication, the physician must prescribe the medication and order
the amount and frequency. Dependent nursing interventions are interventions the nurse may
not initiate on her own.
• Interdependent interventions are also known as collaborative interventions. These
interventions involve all members of the interdisciplinary team. For example, if a patient
had a total knee replacement, his recovery plan may include a prescription medication from
the doctor, assistance with dressing from the nurse or unlicensed assistive personnel, and
physical or occupational therapy by the physical therapist or occupational therapist.
 3. Are Implementation And Intervention The Same In The
Nursing Process?
 While many sources use the words interchangeably, intervention
and implementation are defined somewhat differently. Interventions
are planned nursing activities performed on a patient's behalf. They
include assessment, adherence to medication therapy, and problem-
solving. Implementation is the act of carrying out interventions.
 4. How To Prioritize Nursing Interventions?
 Strategies to prioritize patient care typically include the use of nursing diagnoses
combined with Maslow’s Hierarchy of Needs Theory.
Any nursing diagnosis that suggests a risk or threat to the patient’s survival
should be the nurse’s first priority. Remember your ABCs: Airway, Breathing,
Circulation.
Other physiological needs necessary for survival are considered.
Psychosocial needs are then addressed.
Psychological needs including a sense of love or belonging, self-esteem, and

self-actualization are prioritized last.
 5. Is Giving Meds Part Of Implementation In The Nursing Process?
 Medication administration is part of the implementation phase of the nursing
process steps. The nursing interventions outlined in the planning phase should
include information about medication administration. When the nurse initiates
the action of administering the medication, she is implementing the plan of care.
6. Who Is Responsible for Implementing the Nursing Care Plan?

 All members of the nursing team have roles related to implementing the care
plan. In the planning phase of the nursing process, the Registered Nurse
determines which tasks may be delegated to Licensed Practical/Vocational
Nurses, Nursing Assistants, or other members of the healthcare team. It is
essential to remember that, even if a task is delegated, the RN in charge of the
patient’s care is accountable for making sure all tasks are completed.
STEP #5: EVALUATION PHASE
What Is The Evaluation Phase?

Evaluation is the final phase of the nursing process. Although evaluation is
considered the last of the nursing process steps, it does not indicate an end to
the nursing process. Instead, evaluation should be an ongoing process carried
out in daily nursing activities that ensures quality nursing interventions and
the effectiveness of those interventions.
What Are The Top 3 Reasons Why The Evaluation Phase Is Important?
The evaluation phase of the nursing process is important because it fulfills
several purposes. The following are the top three reasons why this phase is
essential in the nursing process.
1. The primary purpose of an evaluation is to determine the patient’s progress

toward achieving established goals and outcomes.
2. Through evaluation, it is possible to determine a healthcare agency’s ability
to provide safe and effective healthcare services.
3. Evaluation provides a mechanism to help nurses define, explain, and
measure the results of nursing interventions.
What Are The 5 Main Objectives Of The Evaluation Phase?
 The Standards of Clinical Nursing Practice established by the American Nurses
Association designates evaluation as a fundamental component of the nursing process.
This phase of the nursing process has the following objectives.
1. To determine if nursing interventions are helping clients achieve expected

outcomes.
 The effectiveness of nursing interventions is determined by evaluating goals and
expected outcomes to determine if they provide direction for patient care. It is essential
to evaluate nursing interventions because they serve as standards by which patient
progress is measured.
 2. To verify the quality of nursing care provided.

 The evaluation phase is not meant to make nurses feel as if their work is being critiqued
or judged. Evaluation allows nurses to verify if the care they are providing meets the
standard of care for the patient’s needs.
3. To promote accountability among nurses.
 Evaluation involves reviewing all aspects of the patient’s care and determining its
effectiveness in helping the patient recover. Because nurses work collaboratively with
one another and other members of the healthcare team, the evaluation phase promotes
the nurses’ sense of accountability to their patients and to one another.
4. To analyze current data.

 In the evaluation phase of the nursing process, nurses compare and analyze data from
the time the patient was admitted to care and determine if positive or negative trends
are occurring. This data is helpful in deciding the next course of action to take in
patient care.
5. To promote continuity of care.
 Although the evaluation phase is the fifth and last step in the nursing process, nurses
constantly evaluate patient progress. Evaluation allows nurses to establish a pattern of
continuous care and attention, which helps promote positive patient outcomes.
What Skills Are Required For The Evaluation Phase?
 The evaluation phase of the nursing process is primarily based on the nurse's
accurate and efficient use of observation, critical thinking, and communication
skills.
Some changes in a patient's status may be subtle, requiring sharp observational

skills. The ability to analyze reassessment data and use critical thinking are
necessary to determine if outcomes have been met or decide if changes in the
care plan are needed. As in other phases of patient care, the nurse must
demonstrate strong communication skills, as evaluation includes the patient and
all members of the healthcare team.
What Exactly Does The Evaluation Phase Involve?
During the evaluation phase of the nursing process, nurses determine the patient’s
response to interventions and whether goals have been met. The evaluation process
consists of seven steps, as follows.
• Determine if Established Standards Were Met:

Standards and goals are established during the planning phase of the nursing process steps
and carried out in the implementation phase. Nurses use evaluation to determine the
presence of changes in the patient's status relevant to the established standards.
• Data Collection:
The nurse uses assessment skills early in the nursing process to gather data used to
establish goals and expected outcomes. Those same skills are vital for comprehensive,
effective evaluation to occur. Nurses gather data to help determine the success of nursing
interventions.
• Using Data to Determine Goal Achievement:
The data collected during the evaluation phase must answer the question, “Did the
patient achieve the treatment goals and expected outcomes outlined in the care
plan?” Nurses validate goal achievement by analyzing the patient’s response to
nursing interventions outlined in the nursing care plan.
• Examine the Relationship of Nursing Interventions to the Patient’s Status:

Effective nursing interventions address relevant patient needs. If the nursing
intervention is efficient, it can be a primary factor related to helping clients resolve
actual or potential problems or risk factors.
• Evaluate Whether the Nursing Interventions Contributed to Improved Patient Status:
During the evaluation phase, the nurse must use critical thinking skills to determine which nursing
actions contributed to improved patient outcomes and to what degree they were effective. This step in
the evaluation process allows the nurse to analyze the patient's response to interventions, determine the
benefits of those interventions, and identify opportunities or needs for change.
• Reassessment:
In the evaluation phase of the nursing process, the nurse uses observation and assessment skills to
reevaluate the patient's status. In this step, the nurse compares baseline data collected in the initial
nursing assessment with the patient's current health status.
• Modifying the Nursing Care Plan:

If the evaluation determines a lack of progress toward established goals, the nursing care plan is
revised or modified. At this point, revisions are developed by beginning the nursing process anew. The
client is reassessed (Assessment), more appropriate nursing diagnoses are established (Diagnosis), new
or revised goals and outcomes are developed (Planning), new nursing interventions are implemented, or
previous interventions are repeated to maximize effectiveness (Implementation). Then the patient's
response is reevaluated (Evaluation).
5 Common Challenges You Will Face During The Evaluation Phase And How To Overcome
The evaluation phase of the nursing process is the point where nurses and patients hope to see measurable
improvement. The following are a few challenges nurses may face when in the evaluation phase.
Challenge #1: Incomplete Documentation

 Every nurse is responsible for documenting patient progress and other pertinent information. If one
nurse fails to document and report patient changes or progress, or to record laboratory or diagnostic
test results, it can lead to challenges when it is time for the evaluation phase.
How to Overcome:
 The most effective way to overcome this challenge is to avoid it happening altogether. Be sure to
document information about your patients during each shift. Any change in status, progress or lack of
progress, subjective and objective findings, or other relevant information should be readily available
for any nurse caring for that patient.
 Challenge #2: Patient Frustration
 In a perfect world, patients would be admitted to care, nursing interventions would be
implemented, and we would see positive results. Unfortunately, it doesn’t always work that way.
One of the challenges nurses face in the evaluation phase is frustration related to slow progress or
failing to meet goals.
How to Overcome:
 Overcoming the challenges that occur when patients become frustrated takes patience and
understanding.
If you find yourself in the evaluation phase of the nursing process steps and faced with this
situation, take the time to talk to your patient. Assure them that progress does not always happen
as quickly as we would like and encourage them to keep pressing forward.
Let your patient know that you are there to support and help them and that your priority is to see
them improve. Sometimes all it takes to calm a patient and help them regain focus is an assuring
word and calming presence.
 Challenge #3: Patients Withholding Information
 It is not uncommon for patients to try and mask symptoms or deny concerns
when nurses evaluate their progress. This is especially common when a patient
has been hospitalized or in a care facility for an extended period and wants to
return home.
How to Overcome:
 In situations like this, a strong nurse-patient relationship and good
communication skills are necessary. If you feel your patient is not being
forthcoming about their progress, or perhaps new symptoms have emerged that
they do not want to discuss, ask direct questions. Explain the importance of
transparency when reporting progress, problems, or concerns.
 Challenge #4: Family Denial of the Patient’s Need for Continued Care
 As nurses, we naturally hope that interventions positively impact our patients and that
we can see improvement when evaluating them. Family members hope to see their
loved ones recover and return to normal, as well. A significant challenge nurses can face
when evaluating patient progress occurs when the patient's status declines or there is
little improvement and family members deny the reality of the patient's situation.
How to Overcome:
 Many times, the fear of the unknown or lack of understanding is what causes family
denial. If family members struggle with accepting the idea of continued care or changes
in the plan of care, the nurse should acknowledge their concerns and offer support.
When appropriate, talk with the patient and family together and discuss the previous
plan of care and any suggestions for alterations or changes and the rationale for them.
 Challenge #5: Patient Wishing to Terminate Care Before Discharge Goals Are
Met
 Nurses understand that patients respond differently to care with some progressing
faster than others, and the evaluation process helps to identify those patients who
need extra time or updated care plans.
Unfortunately, because patients do not always understand the complexities of

interventions and expected outcomes, it can lead to feelings of despair. If patients
slowly progress or fail to meet goals and expected outcomes, their frustration
sometimes leads them to give up or desire to seek care elsewhere
 When faced with this challenge, it is crucial for nurses to approach the patient with an attitude
of empathy and attempt to discuss the patient's concerns. Depending on the patient's status and
ability to understand, it may take some time and reinforced teaching to help them understand
that slow progress is not failure. Explain your view of your patient's current status compared to
his status on admission. Encourage the patient by assuring him that even slow progress is
progress. Offer ideas of ways you think the care plan can be amended to suit his needs and ask
for input.
Remember, despite your best efforts, there may be times when patients decide to terminate care.
Unless the patient has been deemed incapable of making informed decisions, you may not
interfere with his choice to leave your care. It is necessary to document everything you discuss
with the patient and his response to your instructions and education.
If the patient decides to leave your facility's care, there is appropriate paperwork to be signed,
called an A.M.A. (Against Medical Advice) discharge. The charge nurse or physician is usually
responsible for having the patient sign this form and submitting it to administration.
 Real-World Example Of The Evaluation Phase
 In the evaluation phase, the nurse reassesses the patient and determines if goals
and outcomes are being met or if the care plan needs to be modified.
Observations are recorded in the patient’s chart.
04/20/22 @ 1500: After twenty-four hours of nursing intervention, the client

demonstrates adequate cardiac output as evidenced by decreased blood pressure
of 130/78 and pulse rate of 72. The client states his breathing is less labored and
that if he begins to feel short of breath, he lies still to rest. O2 per NC @ 2L
continuous. Observed 500 cc clear, amber urine in the urinal. The patient
continues to have 2+ pitting edema in bilateral lower extremities. MD notified,
awaiting response/order. The client has turned/repositioned q2h to decrease the
risk of impaired skin integrity. No signs of compromised skin integrity noted at
this time. -------D. Leonard, RN
Frequently Asked Questions About The Evaluation Phase
 1. What Is The Primary Purpose Of The Nursing Evaluation Process?
 The primary purpose of evaluation in the nursing process steps is to determine if
patient goals and expected outcomes have been met or if the nursing care plan
needs to be modified.
2. What Are The Steps In The Process Of Evaluation?

 The steps of evaluation in the nursing process include collecting data, comparing
data with desired goals and expected outcomes, analyzing the patient’s response
to nursing interventions, identifying factors impacting the success or failure of
the nursing care plan, continuing, modifying, or terminating the care plan, and
planning future nursing care.
 3. How To Improve The Evaluation Process?
 Although the nursing process is focused on nursing diagnoses and interventions,
each member of the patient’s healthcare team has a role and the actions they take
in patient care can impact the effectiveness of the nursing care plan. Therefore,
the most effective way of improving evaluation in the nursing process, is to
include the patient, family (when appropriate), and all members of the
interdisciplinary team in the process.
4. How Often Should A Nurse Evaluate A Patient?

 Although healthcare facilities and organizations have minimum guidelines for the
frequency of nurse evaluations, it should be an ongoing process involved in
patient care. The patient’s status and the effectiveness of nursing interventions
should be continuously evaluated, and the care plan should be modified, when
necessary.
 5. What Information Does the Nurse Look For in the Evaluation Phase of the Nursing
Process?
 In the evaluation phase, nurses gather much of the same type of information as what is
gathered during the assessment. During this phase, nurses review current vital signs and
laboratory or diagnostic test results. They use information entered into the patient’s chart,
such as nurses’ notes, flow sheets, and other pertinent information. Additionally, during the
evaluation, nurses reinterview the patient and look for both subjective and objective data to
determine if the plan of care was effective.
6. Who Is Responsible For Evaluating the Effectiveness of the Nursing Care Plan?
 The registered nurse assigned to the patient’s care is the primary person responsible for the
evaluation phase of the nursing process. The RN evaluates all information necessary to
determine if the goals and expected outcomes were met or if alterations in the plan are
needed. Keep in mind, however, every member of the nursing care team plays a vital role in
the RN's ability to conduct a thorough evaluation because each person is responsible for
documenting their work and the patient’s response.

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The 5 Nursing Process Steps

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The 5 Nursing Process Steps –

(Learn Each Step in Detail)

ARLENE L. GALON, RN, MAN

The nursing process is a series of steps nurses take to assess

The nursing process as we know it today is based upon the “

 • Establishes plans to meet patient needs

1. Within the legal Scope of Practice

7. Dynamic and Cyclical

1. Establish communication with the patient.

4. Collect objective data.

5. Collect subjective data.

 Assessments are vital to the nursing process. The information

The nurse will also conduct a head-to-toe nursing assessment addressing

It is also necessary to understand the difference between inferences and cues.

Challenge #1: Limited Time

For example, the Health Information Technology for Economic and

No matter which type of assessment you perform, it should be systematic,

If you feel like your patient is withholding information, instead of making

Date of Admission: 04/19/22 Time: 13.30

Admitting Diagnosis: CHF, acute

Allergies: NKDA, no food allergies

 Location: Headache Intensity: Constant, throbbing Pain Scale: 5

Psychosocial: Client is alert, friendly, and answers questions readily; Comprehension:

Substance Use: Client reports previous substance abuse, methamphetamine was

 1. Why Is Assessment The First Step Of The Nursing Process?

3. What Subjective Data Is Collected When Assessing A Patient?

5. How Do Nurses Collect Verbal Data?

7. What Are The Sources From Where Data Is Collected?

9. How Do Nurses Verify Whether The Collected Data Is Accurate Or Not?

11. What Tools And Equipment Are Used To Collect Data?

1. Identify and Define the Problem(s):

2. Identify Risk Factors:

5. Establish a nursing diagnosis:

 Nurses will utilize several skills in the diagnosis phase of the

 The nursing diagnosis is different from a medical diagnosis. It

 About the Challenge:

 About the Challenge:

 About the Challenge:

About the Challenge:

About the Challenge:

• Problem-Focused Nursing Diagnoses focus on a specific problem the patient is

Health promotion nursing diagnoses are usually one-part statements or

 1. What Is The Difference Between Nursing Diagnosis And Medical Diagnosis?

4. What Is The Purpose Of Establishing A Nursing Diagnosis?

6. How Do Nurses Rank Nursing Diagnoses?

 What Is The Planning Phase?

 The American Nurses Association's Standards of Clinical Nursing Practice identifies

3. Establish Expected Outcomes:

5. Document the Care Plan:

Documentation of the care plan includes nursing orders which communicate

About the Challenge:

To overcome the challenge of unrealistic goals, identify what is essential in helping

Nurses can overcome the challenge of limited patient output by promoting a

 About the Challenge:

Risk for Impaired Skin Integrity

 1. What Are The Components Of A Care Plan?

3. How To Set Goals For Short-Term Nursing Care Plans?

Short-term goal example: “Patient will identify and demonstrate behaviors to

Sample nursing diagnosis: “Situational low self-esteem related to change in

What Is The Implementation Phase?

1. Implementation of the nursing process is significant because it involves action

Although some interventions require the skills and knowledge of a registered

5. Documenting Interventions and Patient Response:

Interpersonal skills help nurses establish therapeutic nurse-patient relationships and