The nursing process: assessment, diagnosis, planning, implementation, evaluation
- Fundamental
The nursing process is the orderly method a nurse uses to get to know the patient, decide what they need, act, and check whether it worked.
What it is
The nursing process is the systematic way of thinking and working in nursing care. It has five phases that repeat in a cycle: assessment (collecting data), nursing diagnosis (interpreting the data and identifying problems or risks), planning (setting priorities, measurable goals and interventions), implementation (carrying out the plan) and evaluation (comparing the result with the goal and adjusting the plan). Some texts list outcome identification as a step of its own and describe six steps. In Colombia, Law 911 of 2004 (art. 3) describes the act of care as a dynamic, participatory process to identify and prioritise needs and decide the care plan.
Key points
- It is a continuous cycle: every new piece of data can change the diagnosis, the goals or the interventions.
- It rests on clinical judgment, the result of critical thinking and decision-making: recognising cues, organising them into patterns and forming a hypothesis about the problem.
- It uses evidence-based practice: the best research evidence, clinical expertise and the patient's preferences and values.
- Everything assessed, planned, done and evaluated is recorded in the clinical record.
Components
- Assessment: subjective data (what the person says) and objective data (what is observed and measured).
- Nursing diagnosis: an actual problem, a risk or a readiness to improve health, with its related factors.
- Planning: priorities, measurable goals with a time frame, and interventions.
- Implementation: independent interventions, dependent ones (on a medical order) and collaborative ones with the team.
- Evaluation: goal met, partially met or not met, and the plan adjusted.
What it is for
- It gives individualised care, not one task list for everyone.
- It sets priorities when there are many problems at once.
- It makes communication between shifts and with the rest of the team easier.
- It lets the team measure whether care works and improve quality.
The five phases in one line each
| Phase | Question it answers | Product |
|---|---|---|
| Assessment | What is happening to this person? | Verified subjective and objective data |
| Diagnosis | What problem or risk can nursing address? | Nursing diagnosis statements |
| Planning | What do we want to achieve, and how? | Priorities, measurable goals and interventions |
| Implementation | What is done? | Interventions carried out and recorded |
| Evaluation | Did it work? | Goal met, partially met or not met; plan adjusted |
In nursing practice
- On admission the nurse does a full initial assessment; on every shift, follow-up assessments.
- With sudden deterioration, airway, breathing and circulation come first and help is called before the rest is completed.
- One patient usually has several nursing diagnoses; they are addressed in order of priority.
- The student applies the process under supervision and within the institution's protocols.
Common mistakes
- Skipping assessment and acting by routine.
- Writing goals that cannot be measured, such as «improve general condition».
- Mixing up the medical diagnosis and the nursing diagnosis.
- Not re-evaluating or adjusting the plan when the goal is not met.
- Planning without asking the patient what they expect.
Test yourself
Think of the answer, then tap the question to see it.
What are the five phases of the nursing process?
Assessment, nursing diagnosis, planning, implementation and evaluation, repeated in a cycle.
What happens if evaluation shows the goal was not met?
The nurse reassesses, reviews the diagnosis, the goal and the interventions, and adjusts the care plan.
How does a nursing diagnosis differ from a medical diagnosis?
A nursing diagnosis describes the person's response to their health situation; a medical diagnosis names the disease.
Which article of Colombia's Law 911 of 2004 describes the act of care as a process to prioritise needs and decide the plan?
Article 3.
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Nursing Fundamentals (Open RN), 4.2 Basic Concepts (Open RN, Chippewa Valley Technical College (LibreTexts), 2022); Nursing Fundamentals (Open RN), 4.4 Diagnosis (Open RN, Chippewa Valley Technical College (LibreTexts), 2022); Nursing Fundamentals (Open RN), 4.8 Evaluation (Open RN, Chippewa Valley Technical College (LibreTexts), 2022); Ley 911 de 2004, responsabilidad deontológica para el ejercicio de la enfermería (Secretaría General del Senado de la República, 2004).
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Representative model, for educational purposes only.