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
An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.

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.

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The Nursing Process

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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

The nursing process can be remembered by the common mnemonic ADPIE, which stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation.

The assessment portion of the nursing process is where the nurse will collect data about the patient. This information will encompass physical findings, psychological, cultural, social, family, and nursing histories as well as accessing the medical record and obtaining diagnostic test results.A nurse should not implement interventions until a complete assessment has been done. Exceptions are only in scenarios where the patient will be at risk of immediate injury or death.

The nursing diagnosis is formed after completions of a comprehensive nursing assessment. Nursing diagnosis' are developed by NANDA (North American Nursing Diagnosis Association) and should be prioritized based on Maslow's Hierarchy of Needs.

The planning step of the nursing process includes developing an individualized care plan, setting goals, and identifying expected outcomes. Setting priorities of the nursing diagnosis' is an important step in the plan of care. The planning step of the nursing process includes developing an individualized care plan tailored to the patient, setting short-and-long-term goals, and identifying expected outcomes using the SMART system, an acronym used to set realistic and specific goals, which stands for specific, measurable, attainable, realistic and time-oriented.

Implementation is the step of the nursing process where your prioritized plans are carried out. Be sure to involve both the patient and family in active care. The nurse should always use therapeutic communication techniques for communication during implementation.(Notes: This is the step where we actually intervene to help them, give drugs, educate, monitor.)

Evaluation is the step where the nurse determines if the patient has met the goals in the patient's plan of care. If the patient did not meet the goals, then the nursing process would begin over and reassessment of the client is completed. Be sure to include reasons why the goals were not previously met and modifications to the plan of care to ensure new goals would be completed.

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