Which step of the nursing process includes developing an individualized care plan setting goals and identifying expected outcomes?

The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care.

Assessment

Diagnosis
The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse’s care plan.

Outcomes / Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.

Implementation
Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.

Evaluation
Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.

The Nurse Processor

The nursing process organizes priority nursing actions and facilitates application of critical thinking for nurses delivering care to patients and populations.The nursing process is a cyclical process and has five components: Assessment, Diagnosis, Planning, Implementation, and Evaluation.

6 KEY FACTS

1. Career development
2. The Five Step Nursing Process

By Alexa Davidson, MSN, RN

Updated September 30, 2021 | Published February 25, 2020

Updated September 30, 2021

Published February 25, 2020

Alexa is a health writer and registered nurse with over a decade of experience in neonatal and pediatric cardiac intensive care. After working her way from the Atlantic to Pacific as a travel nurse, she can now be found caring for members of the community in her hometown of Charleston, SC.

As a nurse, your primary duty is ensuring your patients receive safe delivery of care as outlined by the plan of care created by the medical team. Throughout your shift, you will be constantly collecting and analyzing patient information, and you’ll be charged with what to do with this information. By following the nursing process, you’ll take a systematic approach to manage your patients’ needs. The nursing process provides a framework of practice for the nurse to follow to guarantee that the patient has their needs met. In this article, we explain what the nursing process is, and the steps that are involved in this universal nursing tool.

The five steps of the nursing process

The nursing process is an evidence-based, five-step process used to help guide nurses to think holistically about their patient’s overall picture and plan of care. Nurses learn the nursing process during nursing school and informally use this process when taking care of patients in the professional setting.

When planning how a shift will play out with patients, the nurse must use clinical judgment to create a general plan for the day. The nursing process allows the nurse to gather information, prioritize problems, and set goals for each patient. As nurses gain more experience, the nursing process comes naturally when making decisions for patient care.

The steps are as follows:

1. Assessment phase

2. Diagnosis phase

3. Planning phase

4. Implementing phase

5. Evaluation phase

1. Assessment phase

During the assessment phase, the nurse will look at any subjective and objective data collected in the patient’s history. An example of objective data could be oxygen saturation trends from the chart, or documentation demonstrating that the patient’s oxygen liter flow was increased several times overnight. Subjective data could be information you got during nursing handoff- perhaps the overnight nurse mentioned that the patient was looking “air-hungry” and using accessory muscles to breathe.

What you will want to do during the assessment phase is gather all of this information and make your assessment about what is going on. Your nursing assessment starts before you see the patient, but continues throughout the shift. If the physician were to ask you if the patient looked worse than before, you could provide the details you gathered during your nursing assessment.

2. Diagnosis phase

During the diagnosis phase, you’ll take those assessment findings and formulate a few nursing diagnoses that will guide your care for the shift. A nursing diagnosis is separate from the medical diagnosis and will be subjective based on your nursing judgment. A medical diagnosis must be determined by the physician, for example, “acute respiratory failure.” A nursing diagnosis should be more focused on addressing the problems your patient will face during your shift, for example, “impaired gas exchange” or “risk for impaired mobility.” By creating a nursing diagnosis, you’re already prioritizing the patient’s needs.

Because patients often have multiple problems, you’ll want to follow Maslow’s hierarchy of needs to prioritize these problems. For example, addressing the patient’s oxygen requirements are more important than their ability to go for a walk. Creating nursing diagnoses based on the information you have about this patient will help anticipate any challenges you’ll need to address on your shift.

Related: 5 Examples of Critical Thinking Skills

3. Planning phase

The planning phase is also referred to as the outcomes phase and it is the stage that helps the nurse start formulating a plan of action. During this phase, the nurse will create some goals for the shift. What do you want to make sure happens on your shift? Again, safety is the top priority, so you’ll want to plan goals that prioritize airway, breathing and circulation first. Your first goal might be something like, “The patient will maintain an oxygen saturation of at least 92% this shift.”

For each of the medical issues, the nurse must assign a simple, achievable and measurable goal for a positive outcome for the patient. Generally, these are short-term goals and are evaluated on a shift-by-shift basis.

Related: How To Use Smart Goals in Nursing Care Plans

4. Implementing phase

As the nurse, what are the action items you will take to see that these goals are met? During the implementation phase, you’ll create a few nursing interventions to help achieve the patient’s goals. For example, “Will titrate oxygen liter flow to maintain saturations above 92% this shift.”

Once you’ve addressed airway and breathing, you can create additional action items that will help meet the goals from the planning phase. What will help your patient’s oxygen levels stay up? The next goals could be something like, “Will encourage patient to use incentive spirometry 10 times an hour,” or “Will ambulate patient three times a shift and encourage cough and deep breathing.”

Related: Guide to People Management: Definition, Tips and Skills

5. Evaluation phase

The final phase of the nursing process is the evaluation phase. It takes place following the interventions to see if the goals have been met. During the evaluation phase, the nurse will determine how to measure the success of the goals and interventions. For a patient with respiratory issues, one evaluation tool would be to trend the patient’s oxygen saturation levels throughout the shift. Ask yourself, “Were you able to wean the oxygen or did you have to increase the liter flow?”

Here are a few possible outcomes that the nurse can use to classify the intervention:

• Patient's condition improved: Patient maintained O2 saturations above 92% this shift, no use of accessory muscles, the patient is now off oxygen

• Patient's condition stabilized: The nurse was able to wean oxygen this shift

• Patient's condition deteriorated: Oxygen liter flow was increased twice today, continue to monitor

It’s important to set measurable goals so that you can customize the patient’s plan of care if the goals are not being met.

Related: A Day in the Life of a Nurse: Typical Daily Activities and Duties