The Nursing Process: A Comprehensive Guide for Nursing Students

Critical Thinking in Nursing

Critical thinking is a cornerstone of nursing practice, enabling nurses to make sound clinical judgments and provide safe, effective care. It involves the mental process of actively and skillfully analyzing, synthesizing, and evaluating information gathered from observation, experience, and communication to guide decision-making[pmc.ncbi.nlm.nih.gov]. In essence, critical thinking in nursing means “identifying a problem, determining the best solution, and implementing an effective method to resolve the issue” using clinical reasoning skills[nursingworld.org]. This skill is applied continuously as nurses assess patient data, diagnose health issues, plan interventions, implement treatments, and evaluate outcomes.

Critical Thinking Competencies and Skills

Nurses develop a range of critical thinking competencies to navigate complex clinical situations. Key skills include the ability to analyze data (breaking down information to understand its components), infer logical conclusions, and evaluate the credibility of information sources[pmc.ncbi.nlm.nih.gov]. Nurses must also distinguish between facts and opinions, clarify ambiguous concepts, and recognize underlying assumptions[pmc.ncbi.nlm.nih.gov]. For example, during patient assessment, a nurse uses critical analysis to identify relevant cues (such as vital signs or symptoms) and distinguish them from irrelevant details. By applying critical analysis, nurses can ask probing questions to uncover important information and discard the trivial[pmc.ncbi.nlm.nih.gov]. They also use inductive and deductive reasoning: inductive reasoning involves drawing general conclusions from specific observations (e.g. recognizing a pattern of symptoms), whereas deductive reasoning applies general principles to specific cases (e.g. using a known framework like Maslow’s hierarchy to prioritize a patient’s needs)[pmc.ncbi.nlm.nih.gov]. These competencies allow nurses to solve problems creatively and make decisions that improve patient outcomes.

Critical Thinking Attitudes

Beyond cognitive skills, critical thinking in nursing is shaped by certain attitudes and dispositions. Nurses should cultivate intellectual traits that promote open-mindedness and fair-mindedness in their practice. According to research, “the person applying critical thinking works to develop the following attitudes and characteristics: independence of thought, fairness, insight into personal and social factors, humility, spiritual courage, integrity, perseverance, self-confidence, and curiosity.”[pmc.ncbi.nlm.nih.gov] These attitudes are crucial for effective nursing care. For instance, independence of thought means nurses do not rely solely on what they were taught in school but remain open to new evidence and alternative approaches[pmc.ncbi.nlm.nih.gov]. Fairness involves impartiality – making decisions based on evidence rather than personal biases or emotions[pmc.ncbi.nlm.nih.gov]. Intellectual humility is the willingness to acknowledge what one doesn’t know and to revise opinions in light of new information[pmc.ncbi.nlm.nih.gov]. Integrity means critically questioning one’s own knowledge and beliefs, and being honest about inconsistencies[pmc.ncbi.nlm.nih.gov]. Perseverance allows nurses to persist in finding solutions even when problems are complex or interventions fail initially[pmc.ncbi.nlm.nih.gov]. Finally, curiosity and a spirit of inquiry drive nurses to explore causes and possibilities beyond the obvious[pmc.ncbi.nlm.nih.gov]. By embodying these attitudes, nurses can think critically under pressure and provide care that is both effective and ethically sound.

Levels of Critical Thinking in Nursing

Critical thinking ability in nursing develops over time, and nurses often progress through different levels of critical thinking as they gain experience. These levels, as described in nursing literature, include the basic level, the complex level, and the commitment level[nurseslabs.com]. At the basic level, a nurse’s thinking is concrete and based on rules or procedures. Novice nurses often operate at this level – they rely on textbook knowledge and step-by-step guidelines because they have limited experience. They follow protocols strictly (for example, administering medications exactly as per standing orders) without much modification. While this ensures a baseline of safety, it may lack flexibility. As nurses gain experience and confidence, they move to the complex level. Here, nurses begin to analyze and interpret data beyond the obvious. They recognize that a single problem can have multiple solutions and they consider different viewpoints. Complex critical thinkers are more open-minded; they question practices and seek to understand the rationale behind interventions[nurseslabs.com]. They take initiative in decision-making and can adapt care to individual patient needs. Finally, the commitment level is characterized by an ability to make decisions independently and take action on those decisions, often in advocacy for the patient. At this level, nurses integrate critical thinking into their practice so fully that it becomes second nature. They are able to quickly prioritize patient needs and commit to a course of action even in uncertain situations[nurseslabs.com]. For example, an experienced nurse at the commitment level might rapidly decide to alter a care plan in response to a patient’s changing condition and confidently implement the change. This progression in critical thinking levels underscores the importance of experience and continuous learning in nursing – with practice, nurses become more adept at thinking critically and providing expert care.

Nursing Process Overview

The nursing process is the systematic method by which nurses plan and deliver care. It is often described as a five-step cycle: Assessment, Diagnosis, Planning, Implementation, and Evaluation (abbreviated as ADPIE). The nursing process is “a systematic, rational method of planning that guides all nursing actions in delivering holistic, patient-focused care”[nurseslabs.com]. It serves as a framework for critical thinking and clinical decision-making in nursing practice. Each step of the nursing process is interrelated and overlaps with the others; the process is dynamic rather than linear. As nurses gain experience, they learn to move fluidly back and forth among the steps rather than following them in a rigid sequence[nurseslabs.com]. For instance, new nurses might follow ADPIE strictly step-by-step, whereas an experienced nurse might simultaneously collect assessment data and begin planning interventions. Nonetheless, understanding each phase of ADPIE is essential for building a solid foundation in nursing practice.

The nursing process is deeply rooted in nursing theory and standards. It aligns with the nursing metaparadigm – the fundamental concepts of person, environment, health, and nursing[nurseslabs.com] – by focusing on the patient (person), their context (environment), their health status, and the nurse’s role in facilitating health. Nursing theorists such as Ida Jean Orlando were early proponents of a systematic nursing process. In fact, Orlando’s theory (developed in the 1950s) described how the patient’s behavior triggers the nursing process, and the nurse uses analysis and diagnosis of that behavior to identify the patient’s needs[nurseslabs.com]. This idea that the patient’s expressed needs or problems initiate the nursing process is evident in today’s practice. Over time, other theorists and nursing organizations refined the process into the five-step model we use now. The American Nurses Association (ANA) and other professional bodies have incorporated the nursing process into standards of practice, emphasizing that it is the “essential core of practice for the registered nurse to deliver holistic, patient-focused care.”[nursingworld.org] In summary, the nursing process provides a structured yet flexible approach to care that is guided by nursing theory and evidence, ensuring that patient care is systematic, goal-oriented, and responsive to the individual’s needs.

Assessment

Assessment is the first phase of the nursing process and forms the foundation for all subsequent steps. It involves collecting, organizing, validating, and documenting information about a patient’s health status[nurseslabs.com]. During assessment, the nurse gathers data to identify the patient’s current health problems as well as strengths and risk factors. This information is used to form a comprehensive database about the patient’s physical, psychological, sociocultural, and spiritual status[nurseslabs.com]. In practice, the assessment phase begins as soon as the nurse encounters the patient (or even before, if records are reviewed beforehand) and continues throughout the nurse-patient relationship. It is important for assessment to be systematic and continuous – a haphazard or incomplete assessment can lead to missed problems and ineffective care[nurseslabs.com]. By carefully and consistently collecting data, the nurse avoids omitting important information that could impact the patient’s care.

Collection of Data

Data collection in nursing assessment can be broken down into several key components, often remembered by mnemonics for efficiency and completeness. A comprehensive assessment typically includes both subjective data (what the patient reports, such as symptoms or feelings) and objective data (what the nurse observes or measures, such as vital signs or lab results)[nurseslabs.com]. The primary sources of data are the patient themselves, but nurses also gather information from secondary sources such as family members, medical records, lab reports, and other healthcare providers[nurseslabs.com]. A variety of methods are used to collect this data:

Health History Interview: This is a dialogue with the patient (and family if appropriate) to obtain subjective information about their health. The nurse asks questions about the patient’s current concerns (chief complaint), history of the present illness, past medical/surgical history, family history, lifestyle, and any symptoms they are experiencing. Mnemonics like SAMPLE are commonly used to guide a focused health history, especially in emergency situations. SAMPLE stands for Symptoms, Allergy, Medications, Past medical history, Last oral intake, Events leading up to the illness or injury[nurseslabs.com]. Using such a mnemonic ensures that the nurse systematically covers all relevant aspects of the patient’s situation. For example, asking about allergies (A) and medications (M) helps identify potential contraindications or drug interactions, which is critical for patient safety.
Physical Examination: The nurse performs a thorough physical assessment of the patient. This can range from a head-to-toe assessment (involving inspection, palpation, percussion, and auscultation of all body systems) to a more focused exam if the patient has specific complaints. The head-to-toe assessment is often considered the “best way to collect data” in a systematic manner[nurseslabs.com]. It typically begins with general observations (overall appearance, level of consciousness, posture, etc.) and then proceeds from head to toe, evaluating each body system. For instance, the nurse will assess the patient’s vital signs (temperature, pulse, respirations, blood pressure, pain level), then examine the head and neck, chest and lungs, heart, abdomen, extremities, and so on. Mnemonics can be useful during a physical exam as well. For example, when assessing pain or other symptoms, nurses use OLD CARTS (Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Timing, Severity) or similar mnemonics to ensure all qualities of the symptom are explored. In trauma situations, a rapid assessment may use DCAP-BTLS (Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, Swelling) to quickly note soft tissue injuries[nurseslabs.com]. These mnemonics help nurses remember what signs to look for and prevent oversight in critical moments.
Observation: In addition to the formal interview and exam, nurses continuously observe the patient throughout their interactions. This includes observing the patient’s behavior, mood, body language, and environment. For example, a nurse might observe that a patient appears anxious (restlessness, rapid speech) or that their environment at home is cluttered and unsafe (which could be a fall risk). These observations contribute to the overall assessment of the patient’s needs.
Review of Records and Reports: Nurses also collect data by reviewing available medical records, laboratory test results, diagnostic imaging reports, and other sources of information. This provides objective data (like lab values, X-ray findings) and historical context (previous diagnoses, surgeries, etc.) that complement the patient’s self-reported information.

By using these methods, the nurse gathers a rich picture of the patient’s health. It’s important that data collection is holistic – encompassing not just physical factors but also psychological, social, and spiritual aspects. For instance, a nurse assessing a hospitalized patient in pain will note not only the physical manifestations (vital signs, location of pain) but also the patient’s emotional response (anxiety, withdrawal) and social context (family support, understanding of the pain)[nursingworld.org]. This comprehensive approach ensures that the nurse understands the patient as a whole person.

Organizing Data

Once data is collected, the nurse must organize it in a meaningful way. Raw assessment data can be voluminous, so organization helps in identifying patterns or clusters of information. Nurses often organize data according to frameworks or models. A common approach is to use a body systems framework, grouping data by physiological systems (e.g. cardiovascular data, respiratory data, gastrointestinal data, etc.). Another method is to use a functional health patterns framework (such as Gordon’s 11 functional health patterns), which categorizes data into areas like health perception, nutrition, elimination, activity, sleep, cognition, self-perception, role relationships, sexuality, coping, and values. Organizing data by functional health patterns helps in identifying not just disease processes but also how the illness is affecting the patient’s daily life and well-being. Regardless of the framework, the goal is to arrange data so that related cues are together. For example, if a patient reports “I feel short of breath when I walk” (subjective data) and has an elevated respiratory rate and wheezing on auscultation (objective data), these cues should be grouped under the respiratory system or under a pattern like Activity Intolerance. By clustering related data, the nurse can more easily recognize significant findings. In fact, during the diagnostic phase, one of the first tasks is clustering cues – grouping the assessment data into meaningful clusters that may indicate a particular problem[nurseslabs.com]. Organizing data also involves sorting information into significant vs. insignificant. Not every piece of data is equally important. Critical thinking comes into play here as the nurse decides which data are relevant to the patient’s current health issues. For example, a patient’s report of occasional headaches might be less significant in the context of an acute abdominal problem, whereas their blood pressure reading could be very significant if it’s dangerously high. Through organization and clustering, the nurse transforms raw data into useful information that can guide the next steps in the nursing process.

Validating Data

Validation of data is the step of confirming that the assessment information is accurate and complete. It is easy for misunderstandings or errors to occur during data collection – for instance, a patient might misreport their medication dose, or the nurse might misinterpret a symptom. Validation ensures that the nurse “double-checks” the data so that subsequent nursing actions are based on facts. There are several ways to validate data. One common method is to verify subjective data with objective findings. For example, if a patient says they have “no pain” but is grimacing and guarding their abdomen, the nurse should question this discrepancy. The nurse might say, “You mentioned you have no pain, but I notice you’re holding your stomach. Can you tell me more about that?” In this way, the nurse validates whether the patient truly has no pain or if they are downplaying it. Another validation technique is to obtain additional information when something is unclear. If a patient’s history is inconsistent (e.g. they give different accounts of their symptoms at different times), the nurse might clarify by asking more specific questions or consulting a family member. Cross-checking data with other sources is also useful – for instance, verifying a patient’s reported medication list against the medication reconciliation from the medical record can catch omissions or errors. Nurses also validate data by using repeat assessments. If a vital sign seems abnormal or out of context, the nurse will retake it to ensure the reading was correct (for example, rechecking a blood pressure if it was unusually high on first measurement). In essence, validation is about ensuring that what the nurse believes to be true about the patient’s condition is actually true. This step prevents nurses from acting on incorrect assumptions. As one nursing text notes, analysis of data involves “comparing patient data against standards, clustering the cues, and identifying gaps and inconsistencies.”[nurseslabs.com] Identifying inconsistencies is a form of validation – once a gap or inconsistency is found, the nurse takes steps to resolve it (by asking the patient, checking records, etc.). By validating data, nurses maintain the accuracy of the assessment database, which is crucial for making correct nursing diagnoses and planning effective care.

Documenting Data

Finally, during the assessment phase, the nurse must document the collected data in a clear and organized manner. Documentation is the written (or electronic) record of the patient’s assessment findings and any interactions. Excellent record-keeping is fundamental so that the data gathered is accessible to the entire healthcare team and can be referenced during evaluation of care[nurseslabs.com]. In practice, nurses document assessment information in the patient’s chart or electronic health record. This includes recording vital signs, physical exam findings, interview information, and any other relevant observations. The documentation should be factual, accurate, and concise. For example, instead of writing “Patient looks bad,” a nurse would document “Patient appears pale and diaphoretic, with respirations 30/min and labored.” The latter is specific and descriptive. Nurses often use standardized forms or templates for assessment (such as a head-to-toe assessment flowsheet or a nursing admission assessment form) to ensure consistency. Many facilities also use electronic health records (EHRs) that prompt nurses to enter data in specific fields (vital signs, symptoms, etc.). Regardless of the format, the key is that all important data is recorded so that other nurses, physicians, and providers can review it. Good documentation serves several purposes: it provides continuity of care (so that the next nurse on shift knows what was found), it is a legal record of the care provided, and it is used for evaluation and research. As noted in one nursing guide, “excellent record-keeping is fundamental so that all the data gathered is documented and explained in a way that is accessible to the whole health care team and can be referenced during evaluation.”[nurseslabs.com]. In summary, during the assessment phase, nurses collect a wide range of data, organize and validate it to ensure accuracy, and then document it properly. This comprehensive assessment sets the stage for the next phase: forming a nursing diagnosis based on the data collected.

Nursing Diagnosis

Nursing diagnosis is the second step in the nursing process and is often considered the “bridge” between assessment and planning. It involves analyzing the assessment data to identify the patient’s health problems, risks, and strengths, and then formulating nursing diagnostic statements about those issues[nurseslabs.com]. In contrast to a medical diagnosis (which identifies a disease or condition), a nursing diagnosis is a clinical judgment about the patient’s response to actual or potential health problems or life processes[ncbi.nlm.nih.gov]. In other words, it focuses on the patient’s needs, experiences, and functional status in relation to their health condition. For example, a medical diagnosis might be Pneumonia, whereas a nursing diagnosis could be Ineffective Airway Clearance related to increased tracheobronchial secretions as evidenced by cough with thick sputum and wheezing. Here, the nursing diagnosis highlights the patient’s response (difficulty clearing secretions) to the medical condition (pneumonia). The nursing diagnosis is crucial because it drives the nursing care plan – it is the basis for selecting nursing interventions to achieve outcomes for which nurses are accountable[scielo.br]. A well-formulated nursing diagnosis ensures that the care provided is patient-specific and addresses the issues that nursing can influence.

It’s important to distinguish nursing diagnoses from medical diagnoses and other problem labels. Medical diagnoses are made by physicians (or advanced providers) and focus on the disease, injury, or condition that is causing the patient’s signs and symptoms. They typically remain constant for as long as the disease is present and are treated with medical interventions (e.g. medications, surgery). Nursing diagnoses, on the other hand, focus on human responses to health conditions. They can change more frequently as the patient’s condition and responses change, and they are managed through nursing interventions (e.g. education, monitoring, direct care). For example, a patient with a medical diagnosis of Diabetes Mellitus may have nursing diagnoses such as Imbalanced Nutrition: More Than Body Requirements, Knowledge Deficit regarding insulin administration, or Risk for Impaired Skin Integrity. These nursing diagnoses reflect the patient’s specific needs (nutritional habits, learning needs, potential complications) that the nurse can address. Additionally, nurses sometimes deal with collaborative problems, which are certain physiologic complications that nurses monitor and manage in collaboration with other healthcare providers (often physicians). An example of a collaborative problem is Risk for Complications of Immobility: Deep Vein Thrombosis. Here, the nurse’s role is to prevent or detect the complication (through interventions like leg exercises, compression stockings, etc.) and to notify the physician if signs occur so that medical treatment can be given. In summary, while medical diagnoses and collaborative problems are important, nursing diagnoses are unique in that they identify issues that nurses can treat independently as part of their scope of practice. By using standardized nursing diagnoses (often from NANDA-I, the North American Nursing Diagnosis Association International), nurses communicate in a common language about patient problems, which facilitates continuity and quality of care.

Identifying Client Problems, Risks, and Strengths

The process of formulating a nursing diagnosis begins with analyzing the assessment data to identify significant findings. This involves several sub-steps. First, the nurse compares the patient data against normal standards or norms. For instance, if a patient’s blood pressure is 200/110 mmHg, the nurse recognizes that this is significantly higher than the normal range, indicating a problem. By clustering the cues (grouping related signs and symptoms), the nurse can see patterns. For example, clustering cues such as “complains of frequent headaches,” “dizzy when standing,” and “blood pressure 200/110” might lead the nurse to suspect a problem with hypertension and its effects. During analysis, the nurse also identifies any gaps or inconsistencies in the data[nurseslabs.com] – for example, if laboratory results are missing or if the patient’s reported pain level does not match their behavior, these gaps are noted and possibly addressed by further assessment or clarification. After analyzing and clustering the data, the nurse proceeds to identify the client’s health problems, risks, and strengths. This is essentially a step of clinical judgment: the nurse determines what the data mean in terms of the patient’s health status. Health problems can be actual issues that are currently present (e.g. Acute Pain as evidenced by the patient’s reports and vital signs) or potential issues that the patient is at risk for developing (e.g. Risk for Falls due to weakness and use of sedative medication). It’s also important to identify the patient’s strengths and resources – factors that can help in addressing the problems. Strengths might include things like the patient’s positive attitude, support from family, or existing coping skills. Recognizing strengths is important because it allows the nurse to incorporate them into the care plan (for example, involving a supportive family member in care can improve outcomes). In this decision-making step, the nurse may generate a list of possible nursing diagnoses. It is not unusual for a single patient to have multiple nursing diagnoses[nurseslabs.com] – for example, a hospitalized postoperative patient might have Acute Pain, Impaired Physical Mobility, Risk for Infection, and Anxiety all as relevant nursing diagnoses. The nurse will then prioritize these (we will discuss prioritization in the planning section). Once the nurse has a list of tentative diagnoses, the next task is to formulate the diagnostic statements in the proper format.

Nursing Diagnosis Statement: Parts, Types, and Formulation

Nursing diagnostic statements are structured in a specific way to clearly convey the patient’s problem and its context. A nursing diagnosis generally consists of three parts (for an actual diagnosis):

Diagnostic Label (Problem): This is the name of the nursing diagnosis as defined by NANDA-I (e.g. Impaired Gas Exchange, Deficient Fluid Volume, Anxiety). The label describes the patient’s response in a concise term.
Related Factors (Etiology): This part identifies the underlying cause or contributing factors to the problem. It is written after the phrase “related to” (often abbreviated as r/t). The related factors explain why the patient is experiencing the problem. They can be pathophysiologic (e.g. related to decreased cardiac output), treatment-related (e.g. related to effects of chemotherapy), situational (e.g. related to unfamiliar hospital environment), or maturational (e.g. related to adolescent peer pressure). It’s important that related factors are conditions that nursing interventions can address or influence. For example, “related to diabetes” is too vague and not directly modifiable by nursing actions, whereas “related to insufficient knowledge of insulin self-administration” is specific and actionable.
Defining Characteristics (Signs and Symptoms): These are the observable cues or evidence that support the presence of the diagnosis. They are written after “as evidenced by” (abbreviated AEB) or “as manifested by.” Defining characteristics include the subjective and objective data collected from the patient that led to the identification of the problem[nurseslabs.com]. For instance, for a diagnosis of Acute Pain, the defining characteristics might be “AEB patient’s report of pain 8/10, grimacing, and guarding behavior.” In a risk diagnosis, since the problem is not yet present, we do not have defining characteristics; instead, we list the risk factors (the conditions that make the patient vulnerable to the problem) after “related to.”

Using these components, a full nursing diagnostic statement for an actual problem is often written in a three-part format: Problem (NANDA Label) related to Etiology as evidenced by Defining Characteristics. For example: “Impaired Skin Integrity related to pressure from immobility as evidenced by an open ulcer on the sacral area, 2 cm in diameter.” For risk diagnoses, the format is two-part: Risk for [Problem] related to Risk Factors. For example: “Risk for Impaired Skin Integrity related to immobility and poor nutritional status.” For health promotion diagnoses (which focus on the patient’s desire to improve well-being), the format might be Readiness for Enhanced [Health Behavior] (e.g. “Readiness for Enhanced Nutrition”) and this may be followed by as evidenced by the patient’s expressed desire or steps already taken (e.g. “AEB patient stating ‘I want to start eating healthier’ and attendance at a nutrition class.”).

There are several types of nursing diagnoses defined by NANDA-I:

Actual Nursing Diagnosis: Identifies a problem that is currently present in the patient (as evidenced by defining characteristics). Example: “Anxiety related to impending surgery as evidenced by restlessness, increased heart rate, and patient statement ‘I’m really worried.’”
Risk Nursing Diagnosis: Identifies a vulnerability or potential problem that does not yet exist but for which the patient is at high risk. Example: “Risk for Falls related to history of syncope and use of antihypertensive medication.”
Health Promotion Nursing Diagnosis: Focuses on the patient’s motivation and readiness to enhance their well-being or health behaviors. Example: “Readiness for Enhanced Coping” (with evidence that the patient is seeking support or education to improve coping skills).
Possible Nursing Diagnosis: A label that can be used when the nurse suspects a diagnosis but needs more data to confirm it. Example: “Possible Social Isolation” (if the nurse has some cues but not enough to definitively diagnose it yet).
Syndrome Diagnosis: A label that describes a cluster of nursing diagnoses that occur together and are best addressed together. An example is “Post-Trauma Syndrome”, which encompasses multiple related responses (anxiety, sleep disturbances, etc.) following a traumatic event.

When formulating nursing diagnoses, nurses follow certain guidelines to ensure accuracy and usefulness:

Use NANDA-I approved diagnoses: It is recommended to use the standardized labels from NANDA-I (or other recognized classification systems) because they have clear definitions and defining characteristics. This promotes consistency. For example, instead of inventing a label like “Patient is not eating enough,” a nurse would use the NANDA label “Imbalanced Nutrition: Less Than Body Requirements” which has an established meaning.
Write legally and ethically appropriate statements: Avoid judgmental language or blaming the patient. For instance, “Noncompliant related to stubbornness” is inappropriate; a better phrasing would be “Ineffective Therapeutic Regimen Management related to difficulty adhering to complex medication schedule”. The latter focuses on the situation rather than the patient’s character.
Avoid medical diagnoses in the etiology: The related factors should not be a medical diagnosis itself. Instead of “Pain related to appendicitis,” one could write “Acute Pain related to inflammation of abdominal tissues as evidenced by…” This way, the nursing diagnosis remains distinct from the medical diagnosis.
Use specific and precise terms: The diagnostic statement should clearly convey the patient’s unique situation. Vague terms like “related to unknown factors” should be avoided if possible (though sometimes “related to unknown etiology” is used in the case of idiopathic conditions). Instead, be as specific as the data allow.
Ensure the diagnosis is within nursing’s scope to treat: A nursing diagnosis should be something that nursing interventions can impact. For example, “Risk for Shock” might be more appropriately a collaborative problem requiring medical interventions, whereas “Deficient Fluid Volume” is a nursing diagnosis that nurses can manage through fluid replacement and monitoring.

By adhering to these guidelines, nurses create nursing diagnoses that are clear, accurate, and useful for guiding care. Once the nursing diagnoses are formulated, the nurse moves on to the planning phase, where goals and interventions are developed for each diagnosis.

Planning

Planning is the third step of the nursing process and is where the nurse develops a strategy for addressing the patient’s nursing diagnoses. It involves setting goals and expected outcomes and selecting nursing interventions that will help the patient achieve those outcomes[nurseslabs.com]. The planning phase bridges the gap between diagnosis and implementation: it outlines what needs to be done and how to do it. According to nursing literature, “planning is the third step of the nursing process [and] provides direction for nursing interventions.”[nurseslabs.com]. In this phase, the nurse, often in collaboration with the patient and other healthcare providers, decides on the priorities of care, establishes goals for each identified nursing diagnosis, and devises interventions tailored to the patient. The end result of the planning phase is a nursing care plan – a written (or electronic) plan that details the patient’s nursing diagnoses, goals, the interventions to be implemented, and how outcomes will be evaluated. Care plans ensure that care is individualized to the patient’s unique needs and is based on current best practices[osmosis.org]. They also enhance communication among healthcare team members, as everyone involved can refer to the plan to understand the patient’s needs and the strategies in place to meet them[osmosis.org].

There are different types of planning in nursing, depending on the stage of the nurse-patient relationship and the setting. Initial planning is done when the nurse first assesses the patient (often on admission to a healthcare facility) and formulates the initial care plan. Ongoing planning occurs throughout the patient’s stay as the nurse updates the care plan based on new assessment data and the patient’s progress. For example, if a patient’s condition changes or new problems arise, the nurse will add or modify diagnoses and interventions accordingly. Discharge planning is a specific type of planning that begins as early as possible in the patient’s care and focuses on preparing the patient for transition out of the healthcare facility (whether to home, to a rehabilitation center, etc.). Discharge planning ensures that the patient’s needs after discharge are anticipated and addressed (for instance, arranging for home health services or teaching the patient self-care before they leave). Regardless of the type, planning is a continuous, dynamic process – it starts with the first patient contact and continues until the patient is no longer under the nurse’s care[nurseslabs.com]. Nurses often engage in planning at the start of each shift as well, prioritizing the day’s tasks for each patient. By continuously planning and revising the care plan, nurses can respond to the patient’s changing condition and needs in a timely manner.

Establishing Priorities

When multiple nursing diagnoses and patient needs exist, the nurse must determine which problems to address first. Establishing priorities means ordering the nursing diagnoses or patient problems in terms of urgency and importance. This step is critical because it guides the sequence of interventions. Not all problems can be tackled simultaneously, and some are more critical to address immediately than others. A classic framework for setting priorities is based on Maslow’s Hierarchy of Needs. Abraham Maslow’s hierarchy organizes human needs from most basic (physiological) to higher-level needs (safety, love/belonging, esteem, self-actualization). In nursing, this hierarchy is often used to prioritize nursing diagnoses: physiological needs are generally given the highest priority, followed by safety and security needs, then love and belonging needs, esteem needs, and finally self-actualization needs. For example, a patient’s need for oxygen (a physiological need) would take precedence over their need for social interaction. A nursing diagnosis like Ineffective Airway Clearance or Impaired Gas Exchange (which threatens a patient’s oxygenation) would be a high priority, whereas something like Social Isolation might be a lower priority in the acute setting. However, it’s important to note that while Maslow’s hierarchy provides a useful guideline, clinical judgment and the specific patient situation must also be considered. A patient’s perceived urgent need (even if it’s not a basic physiological need) might need to be addressed to gain their cooperation. For instance, a patient in severe emotional distress (anxiety) might not be able to focus on managing their pain (a physiological need) until the anxiety is somewhat relieved. In such a case, the nurse might address Anxiety first as a high priority to then better manage the pain. Nurses often categorize priorities as high priority (life-threatening or requiring immediate attention, e.g. airway, breathing, circulation issues), medium priority (non-life-threatening but requiring attention to prevent complications or deterioration, e.g. acute pain, risk for infection), and low priority (issues that are important but can be addressed after more urgent needs, e.g. knowledge deficit about a chronic disease management when the patient is currently stable). By establishing clear priorities, the nurse can allocate their time and resources effectively, ensuring that the most critical needs are met first. This step also involves collaboration with the patient and family when possible – sometimes patients may have their own priorities for what they want to address (for example, pain control might be the patient’s top priority), and the nurse should respect and incorporate that if feasible, while also educating the patient about other important needs.

Establishing Goals and Expected Outcomes

Once priorities are set, the nurse works on establishing goals and expected outcomes for each nursing diagnosis. A goal is a broad statement of what the nurse and patient hope to accomplish in relation to the nursing diagnosis. It is usually related to resolving or improving the problem identified. An expected outcome is a specific, measurable criterion that indicates progress toward meeting the goal. In practice, goals and outcomes are often written together, with outcomes being the observable steps that lead to the goal. For example, for the nursing diagnosis “Acute Pain related to surgical incision as evidenced by pain rating 8/10 and guarding behavior,” a broad goal might be “Patient will experience relief of pain”. The expected outcomes to measure this goal could be: “Patient will report pain intensity ≤ 3/10 within 30 minutes of receiving analgesic,” and “Patient will demonstrate relaxed body posture and absence of grimacing within 1 hour.” These outcomes are specific and allow the nurse to evaluate whether the goal was met. It’s important that goals and outcomes are patient-centered, realistic, and time-bound. A common mnemonic to ensure outcomes are well-constructed is SMART, which stands for Specific, Measurable, Achievable, Relevant, and Time-bound. Using SMART criteria helps nurses write outcomes that are clear and trackable. For instance, instead of a vague outcome like “Patient will feel better,” a SMART outcome would be “Patient will verbalize relief of nausea (rating 0/10 on a 0–10 scale) within 30 minutes of antiemetic administration.” This outcome is specific (nausea relief), measurable (0/10 scale), achievable (given an antiemetic is effective), relevant to the nursing diagnosis (e.g. Nausea), and time-bound (within 30 minutes).

Goals can be short-term or long-term. Short-term goals are expected to be achieved in a relatively short period, often within hours or days. They are useful for immediate problems or as steps toward a larger goal. For example, “Patient will ambulate 50 feet with assistance by the end of the day” is a short-term goal for a postoperative patient. Long-term goals may take days, weeks, or even months to achieve and are often related to broader health management or rehabilitation. For instance, “Patient will independently perform all ADLs (activities of daily living) within 6 weeks” could be a long-term goal for a patient recovering from a stroke. Both types of goals are important: short-term goals provide frequent feedback on progress and keep the patient and nurse motivated, while long-term goals provide an overarching direction for care.

When writing goals and outcomes, nurses should also consider the patient’s involvement and agreement. Whenever possible, the patient (and family, if appropriate) should participate in setting goals. This increases the patient’s commitment to achieving them. For example, if a patient has a nursing diagnosis of “Imbalanced Nutrition: More Than Body Requirements”, a collaborative goal might be “Patient will lose 1 pound per week over the next 8 weeks through dietary modifications and increased exercise.” This goal is more likely to be achieved if the patient is on board with it. Additionally, goals should be realistic and individualized. They should take into account the patient’s health status, resources, and limitations. A goal that is too ambitious or not tailored to the patient (for instance, expecting a frail elderly patient to run a mile in a week) is not useful and can lead to discouragement. Instead, goals should build on the patient’s strengths and be adjusted as needed based on the patient’s progress.

In summary, establishing goals and outcomes is a vital part of planning. Goals give direction to nursing interventions (they answer the question “What are we trying to accomplish?”), and expected outcomes provide the criteria by which success will be measured. By setting clear, patient-centered goals and outcomes, nurses can evaluate later whether their nursing interventions were effective. This step also helps in communicating with other healthcare team members about what the patient’s targets are. For instance, if the goal is for the patient to ambulate independently by discharge, the physical therapist and other nurses will align their interventions with that goal. Well-defined outcomes ensure accountability and help in demonstrating the impact of nursing care on patient health.

Selecting Nursing Interventions

After determining goals and outcomes, the nurse proceeds to select nursing interventions that will help achieve those outcomes. Nursing interventions are the actions or activities that a nurse performs to carry out the care plan. They include any treatment, based on clinical judgment and knowledge, that a nurse executes to enhance patient outcomes[usa.edu]. Interventions can range from direct care measures (like administering medication, performing a wound dressing change, or providing emotional support) to indirect care measures (like coordinating with other providers or setting up a referral). There are several types of nursing interventions:

Independent Nursing Interventions: These are actions that nurses are licensed to initiate on their own, based on their professional knowledge and judgment, without needing a physician’s order. Examples include teaching a patient about post-discharge care, performing a bed bath, repositioning a patient to prevent pressure ulcers, or assessing a patient’s pain level. These interventions are within the scope of nursing practice and often relate directly to managing the nursing diagnoses.
Dependent Nursing Interventions: These are actions that require an order from a physician or another provider. The nurse carries out these interventions under the direction of the physician. Examples include administering a medication (which requires a doctor’s order), performing a specific lab test, or preparing a patient for surgery. Even though a physician’s order is needed, the nurse is responsible for ensuring the intervention is appropriate and safe and for monitoring its effects.
Collaborative (Interdependent) Interventions: These involve working with other healthcare team members to implement the intervention. For example, “collaborate with physical therapy to establish an exercise regimen” or “consult with a dietitian to adjust the patient’s meal plan.” The nurse may initiate the collaboration, but the action is carried out in partnership with others. Collaborative interventions are common for complex patient needs that require multiple disciplines.

Nurses select interventions based on the patient’s specific nursing diagnoses and goals, as well as on evidence-based practice. It is important that the interventions chosen are appropriate for the patient’s condition and likely to achieve the desired outcomes. To guide intervention selection, nurses often refer to protocols, clinical guidelines, or standardized care plans. Protocols and standing orders are pre-written plans that outline interventions for certain situations. For example, a hospital might have a standing order protocol for managing a patient with chest pain: the nurse can initiate certain interventions (like administering oxygen, obtaining an ECG, giving aspirin) immediately upon recognizing chest pain, without waiting for a doctor’s order, because the protocol permits it. Protocols ensure prompt, consistent care in critical situations. Clinical practice guidelines (often developed by professional organizations) provide evidence-based recommendations for interventions in specific conditions. For instance, an evidence-based guideline for “Prevention of Pressure Ulcers” might recommend interventions such as repositioning the patient every 2 hours, using pressure-relieving devices, and assessing nutritional status – these would inform the nurse’s care plan for a patient at risk for skin breakdown. By using protocols and guidelines, nurses ensure that their interventions are grounded in best practices and are effective.

Nurses also have classification systems to help organize and select interventions. The Nursing Interventions Classification (NIC) is a comprehensive, standardized list of nursing interventions developed by the Iowa Intervention Project. It contains hundreds of intervention labels (and definitions) that nurses can use to describe the care they provide. For example, under NIC, there are interventions like “Pain Management,” “Fall Prevention,” “Teaching: Prescribed Medication,” etc. Each NIC label has a definition and a list of activities that a nurse would perform for that intervention. Using NIC (or similar classification systems like NOC, Nursing Outcomes Classification) can bring consistency to care planning and documentation. In fact, research has shown that using standardized terminologies like NIC and NOC in care plans can improve the quality of care by providing clearer communication and evidence-based direction[pmc.ncbi.nlm.nih.gov]. Nurses may not always explicitly write NIC labels in a care plan, but these classifications influence nursing practice and electronic health record systems. They help in standardizing care plans across institutions and in evaluating the effectiveness of nursing interventions on a broader scale.

When writing out the nursing interventions in the care plan, nurses should be specific about what will be done, how it will be done, and when or how often it will be done. For example, instead of writing “Monitor patient’s pain,” a more useful intervention is “Assess pain level on a 0–10 scale every 2 hours and after any intervention for pain, and document findings.” The latter specifies the action (assess pain), the method (0–10 scale), the frequency (every 2 hours and after interventions), and the follow-up (documentation). Such specificity ensures that any nurse reading the care plan knows exactly how to implement the intervention. It also makes evaluation easier (you can check if the intervention was indeed done every 2 hours as planned). Additionally, interventions should be tailored to the patient – taking into account the patient’s preferences, values, and individual circumstances. For instance, if a patient is culturally averse to certain interventions, the nurse should respect that and perhaps find an alternative that is acceptable (with the goal of not compromising care). In all cases, interventions should be safe and evidence-based. Before implementing any intervention, a nurse should consider the 5 rights of delegation (if delegating to another caregiver) and the 6 rights of medication administration (if giving medication), etc., to ensure patient safety.

In summary, selecting nursing interventions is a creative yet evidence-guided step. The nurse uses clinical knowledge, past experience, and available resources (protocols, guidelines, NIC) to choose interventions that will best help the patient achieve the established goals. The interventions should be individualized, specific, and collaborative (when appropriate). Once the interventions are chosen, they are documented in the care plan. Next, the nurse will put these interventions into action during the implementation phase.

Developing the Nursing Care Plan

The culmination of the planning phase is the creation of the nursing care plan (NCP). A nursing care plan is a formal document that outlines the plan of care for a patient, based on the nursing assessments and diagnoses. It serves as a roadmap for the nursing interventions to be delivered and as a means of communication among healthcare providers. A well-developed care plan ensures that care is organized, consistent, and patient-centered. In fact, without a care planning process, the “quality and consistency of patient care would be lost.”[nurseslabs.com]. The care plan typically includes the following components for each nursing diagnosis:

Nursing Diagnosis: The label and the related factors (and as evidenced by, if an actual diagnosis).
Goals/Expected Outcomes: The broad goal and specific measurable outcomes for that diagnosis.
Nursing Interventions: The actions to be implemented, often with a rationale and frequency.
Evaluation Criteria: How the nurse will determine if the outcomes were met (this is sometimes implicit in the expected outcomes, which are measurable).

Care plans can be written in a variety of formats. In some facilities, nurses use a problem-oriented format, listing each problem (diagnosis) and the corresponding goals and interventions. In others, an electronic care plan system might be used, where the nurse selects from drop-down menus of diagnoses, outcomes, and interventions (these systems often incorporate standardized languages like NANDA, NIC, NOC). There are also standardized care plans for common conditions (for example, a standard care plan for “Pneumonia” or “Postoperative Care”) that nurses can use as a template and then individualize for their patient. Using standardized care plans can save time and ensure that common interventions are not overlooked. Research has demonstrated that evidence-based standardized care plans can serve as “standards of care, documentation templates, and clinical decision support reminders,” reinforcing best practices in care[pmc.ncbi.nlm.nih.gov]. However, it’s crucial that any standard plan is tailored to the individual patient’s needs – no two patients are exactly alike, so the care plan should reflect the patient’s unique strengths, preferences, and circumstances.

When writing or updating a care plan, nurses should follow some general guidelines:

Individualize the care plan for the patient: Avoid using a “cookie-cutter” approach. The care plan should include the patient’s name, age, and specific details. For example, instead of a generic goal like “Patient will have improved nutrition,” it should be specific to the patient, such as “Mr. Smith will consume at least 75% of each meal by tomorrow.”
Use measurable outcomes: As discussed, outcomes need to be objective and measurable so that evaluation is clear. This also makes the care plan more useful – if you can’t measure it, you can’t tell if it was achieved.
Include realistic and time-bound goals: Ensure that goals have a time frame (short-term or long-term) and that they are achievable given the patient’s situation. Unrealistic goals can lead to frustration and may indicate a need to revise the plan.
Include both nursing orders and collaborative orders: The care plan should note which interventions require a physician’s order and which are independent nursing actions. For example, if “Administer acetaminophen for pain” is an intervention, it should be noted that this requires an order (unless it’s a standing order). If “Teach patient deep breathing exercises” is an intervention, that’s an independent action the nurse can do.
Document the plan clearly and concisely: Use clear language and avoid jargon that others might not understand. If using abbreviations, ensure they are standard and approved. The care plan should be legible (in electronic form or handwriting) and kept in the patient’s record where all team members can access it.
Review and update the care plan regularly: Planning is continuous. The nurse should revisit the care plan each shift or at regular intervals to see if goals are being met, if new problems have emerged, or if interventions need to be changed. For example, if a patient’s pain is well-controlled, the intervention frequency for pain assessment might be decreased. Conversely, if a patient develops a new complication, a new nursing diagnosis and interventions should be added to the plan.
Involve the patient and family in the care plan: Whenever possible, the patient’s input should be reflected in the care plan. This might include the patient’s preferences for certain interventions, their goals, and how they want to be involved in their care. For instance, if a patient prefers non-pharmacological pain relief methods, the care plan can include those as primary interventions with medication as a backup. Involving family can also help, especially for discharge planning (e.g. if a family member will be assisting with care at home, their training can be part of the plan).

By following these guidelines, nurses ensure that the care plan remains a relevant and effective tool throughout the patient’s care journey. The nursing care plan is not just a paperwork exercise; it is a living document that guides nursing actions and demonstrates the nurse’s commitment to thoughtful, organized care. In many healthcare settings, the care plan is shared with the patient (or their family) in an understandable way, so that everyone is on the same page about what to expect and how to work together to achieve health goals.

Implementation

Implementation is the fourth step of the nursing process, during which the nurse puts the care plan into action. It involves carrying out the nursing interventions that were planned to achieve the patient’s goals[nurseslabs.com]. In essence, this is the “doing” phase – turning plans into actions. During implementation, the nurse actually performs (or delegates) the interventions and monitors the patient’s response as the interventions are delivered. According to one nursing resource, “the implementation phase of the nursing process is when the nurse puts the treatment plan into effect. It involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care.”[nurseslabs.com]. This phase is where the nurse’s knowledge, skills, and critical thinking all come together in direct patient care. Implementation may involve a wide range of activities, from administering medications and performing procedures to providing emotional support and patient education. It’s important to note that implementation does not occur in isolation – the nurse continues to assess the patient during this phase and may need to modify interventions on the fly if the patient’s condition changes. Thus, implementation is closely intertwined with assessment and evaluation. For example, as a nurse is administering an intervention (say, giving a pain medication), they are also observing the patient’s response (assessing if the patient’s pain is starting to decrease or if any adverse effects occur) and evaluating whether the intervention is having the desired effect (is the patient becoming more comfortable?).

Before implementing an intervention, the nurse should perform a quick double-check or “five rights” verification to ensure safety. For interventions like medication administration, this means verifying the right patient, right drug, right dose, right route, right time, and also checking the right indication (to make sure the medication is appropriate for the patient’s condition). For other interventions, similar checks apply – for instance, before performing a procedure, the nurse confirms they have the right equipment and that they have identified the patient correctly. This step helps prevent errors. Additionally, the nurse should ensure that the patient is prepared and consenting (to the extent possible) for the intervention. If the patient is unable to consent (e.g. unconscious), the nurse acts under the assumption of implied consent for life-saving measures. Communication is key during implementation: the nurse should explain to the patient what they are doing and why, and involve the patient in the process when appropriate (for example, teaching the patient how to assist with deep breathing exercises as the nurse guides them). This not only ensures patient cooperation but also empowers the patient and reduces anxiety.

Nursing interventions during implementation can be categorized as direct care or indirect care activities:

Direct Care Interventions: These are actions that the nurse performs in the presence of the patient. They involve direct interaction between the nurse and the patient. Examples of direct care include administering a medication, performing a physical assessment, providing wound care, assisting with mobility exercises, counseling a patient who is anxious, or teaching a patient how to use an inhaler. Essentially, any hands-on or face-to-face care given to the patient is a direct intervention. Direct care is often what people think of when they imagine nursing – the nurse at the bedside providing care. Direct interventions can be brief (like taking a blood pressure) or more extended (like sitting with a patient who is upset to provide emotional support). A special type of direct care is physician-initiated interventions (dependent interventions) which the nurse carries out under medical orders (for example, inserting a Foley catheter as ordered by a physician). Even though the order comes from a physician, the nurse’s direct action is required to implement it.
Indirect Care Interventions: These are actions that the nurse performs on behalf of the patient but not in the patient’s immediate presence. They are aimed at facilitating the patient’s care and improving the environment in which care is delivered. Examples of indirect care include coordinating care with other healthcare team members, documenting in the patient’s chart, communicating patient status during shift report or to physicians, advocating for the patient (such as requesting a consult or more pain medication from the physician), managing the patient’s environment (ensuring it’s safe and clean), and educating or supervising other staff or family members who will be involved in the patient’s care. Another example is case management activities, like arranging for home health services before the patient is discharged. All these activities benefit the patient indirectly – they support and enhance the overall care experience even though the patient may not be directly aware of them at the time. For instance, when a nurse spends time coordinating with a physical therapist to schedule an early morning session for a patient, the patient benefits from the timely therapy (which can aid recovery), but the actual coordination work is done behind the scenes by the nurse. Indirect care is an important part of the nurse’s role, especially in complex healthcare systems where multiple providers are involved. It ensures that the patient’s care is continuous and well-organized.

During implementation, nurses also need to exercise clinical judgment and be prepared to adapt. Not every intervention will go exactly as planned. A patient’s condition might change, or an intervention might not be effective. In such cases, the nurse uses critical thinking to decide how to proceed. This might involve modifying the intervention (for example, if a patient is unable to take an oral medication due to nausea, the nurse might contact the physician to switch to a different route), or adding a new intervention (if a patient develops a new symptom, the nurse might initiate a new action to address it). The nurse is also responsible for delegation during implementation when appropriate. Delegation means assigning certain tasks to other qualified personnel (like licensed practical nurses or nursing assistants) while retaining accountability for the outcome. Nurses must follow their institution’s policies and their state’s nurse practice act when delegating. For example, a registered nurse (RN) might delegate taking vital signs to a nursing assistant, or delegating a simple dressing change to an LPN, depending on training and regulations. Effective delegation allows the nurse to manage their workload and focus on higher-level tasks, but the nurse must ensure that the delegated task is done correctly and that they follow up on the results.

Throughout the implementation phase, documentation is ongoing. The nurse records what interventions were performed, who performed them, when they were performed, and the patient’s response to each intervention. This is done in the patient’s chart or electronic health record. Accurate documentation during implementation is crucial for several reasons: it provides a record of the care given (which is important for continuity and legal purposes), it helps in evaluation (you can’t evaluate an intervention if you didn’t document doing it), and it communicates to other providers what has been done. For example, if a nurse administers pain medication, they should document the medication, dose, route, time, and then later document the patient’s pain level after the medication. This documentation loop shows whether the intervention had the intended effect. If multiple nurses are caring for the patient (shift changes, etc.), the documentation allows the next nurse to know what interventions were done and the patient’s status. In summary, implementation is the phase where nursing care is delivered. It requires a combination of technical skills, interpersonal skills, and critical thinking. By executing interventions safely and effectively, and by continuously observing the patient’s responses, the nurse moves the patient closer to the desired outcomes. The implementation phase sets the stage for the final step in the nursing process: evaluation, where the nurse will assess whether the interventions were successful in achieving the goals.

Evaluation

Evaluation is the fifth and final step of the nursing process (though in the cyclic nature of nursing care, it also feeds back into assessment). Evaluation involves assessing the patient’s progress toward the identified goals and determining the effectiveness of the nursing interventions[nurseslabs.com]. In essence, it is the step where the nurse asks, “Did the nursing interventions make a difference, and were the goals met?” The evaluation phase is critical because it provides feedback on the care plan: if goals are met, the nurse knows the interventions were effective; if not, the nurse must explore why and adjust the plan accordingly. According to the American Nurses Association, “both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.”[nursingworld.org]. This highlights that evaluation is not a one-time event at the end, but rather an ongoing process throughout the patient’s care. Nurses evaluate outcomes as soon as possible after interventions (for instance, evaluating pain relief shortly after giving an analgesic) and continue to evaluate on an ongoing basis (like at the end of a shift, or each day, or at the time of discharge).

To evaluate effectively, the nurse uses the expected outcomes that were established in the planning phase as the criteria for success. Because those outcomes were written in measurable terms, the nurse can compare the patient’s actual status against those criteria. For example, if an expected outcome was “Patient will ambulate 50 feet with assistance by 10/15/2025,” the nurse will check on 10/15/2025 whether the patient can indeed walk 50 feet with assistance. There are a few possible conclusions in evaluation:

Goal met: The patient has achieved the expected outcome. For instance, “Patient ambulated 50 feet with assistance on 10/15/2025” – goal met.
Goal partially met: The patient has made progress toward the outcome but has not fully achieved it. For example, “Patient ambulated 20 feet with assistance on 10/15/2025 (goal was 50 feet)” – partially met.
Goal not met: The patient has not achieved the outcome to any significant degree. For instance, “Patient was unable to ambulate on 10/15/2025 due to weakness” – goal not met.

When evaluating, the nurse should also assess why a goal was met or not. If a goal was met, the nurse can note which interventions were particularly effective. If a goal was not met or only partially met, the nurse needs to analyze potential reasons. This might involve reviewing the entire nursing process up to that point: Was the assessment complete and accurate? Was the nursing diagnosis appropriate for the patient’s problem? Were the goals and outcomes realistic and correctly written? Were the interventions properly selected and implemented? Sometimes the issue is that the interventions were not carried out as planned (maybe due to a staffing issue or an oversight), or perhaps the patient did not comply with certain interventions. Other times, the problem might be that the patient’s condition changed or was more complex than initially thought, making the original goals too optimistic. The nurse uses critical thinking during evaluation to identify contributing factors. For example, if a patient’s blood pressure did not decrease as expected despite interventions, the nurse might find that the patient was not taking the prescribed antihypertensive medication as instructed (non-compliance) or that the diet modifications were not fully implemented. Alternatively, the nurse might realize that the nursing diagnosis “Ineffective Health Maintenance” might be more appropriate than the initial diagnosis, or that a collaborative problem (like uncontrolled hypertension) needs to be addressed with medical management changes. In essence, evaluation often leads back to assessment and diagnosis – it closes the loop in the nursing process cycle.

During the evaluation phase, the nurse also documents the findings. It is important to record whether each outcome was met, and if not, to note the progress made and the reasons for lack of progress. This documentation is part of the patient’s record and informs future care decisions. For example, a nurse might document: “Goal: Patient will have pain ≤ 3/10 within 30 minutes of analgesic – partially met. 30 minutes after morphine administration, patient reports pain 5/10. Pain level decreased from 8/10 to 5/10. Will continue current pain regimen and reassess. Patient may require higher dose or adjunct therapy.” This kind of documentation shows accountability and provides clear information to other healthcare providers. In many institutions, nurses use an evaluation scale or specific notation (such as “Met,” “Partially Met,” “Not Met”) for each outcome in the care plan.

Based on the evaluation, the nurse will then terminate, continue, or modify the care plan:

Terminate: If a goal is fully met and the underlying nursing diagnosis is resolved, that portion of the care plan can be terminated. For example, if a patient’s Acute Pain has been managed and the patient is discharged pain-free, the Acute Pain diagnosis and related interventions can be discontinued.
Continue: If a goal is still in progress (partially met) and the nursing diagnosis is still relevant, the nurse continues the current plan of care. For instance, if a patient is improving but still needs assistance with mobility, the Impaired Physical Mobility diagnosis remains, and interventions like physical therapy and ambulation assistance continue.
Modify: If a goal is not met or if new problems have emerged, the care plan needs modification. Modification can involve revising the assessment (perhaps doing a more thorough assessment in that area), changing the nursing diagnosis (maybe a different diagnosis is more appropriate now), setting new or revised goals/outcomes (perhaps making them more realistic or adjusting the time frame), or changing the interventions (adding new interventions, discontinuing ineffective ones, or altering the frequency). For example, if a patient’s Risk for Infection goal (no signs of infection by discharge) was not met because the patient developed a fever and an infection, the nurse would add an actual nursing diagnosis like “Infection related to surgical wound as evidenced by purulent drainage and fever,” set new goals for resolving the infection, and implement interventions such as antibiotic administration and wound care. Modification of the care plan ensures that it remains responsive to the patient’s current condition.

It’s worth emphasizing that evaluation is continuous. Nurses are constantly evaluating patient responses in real-time. For example, while administering care, a nurse evaluates if the patient is tolerating the intervention well (is the patient in distress? is there an adverse reaction?). At the end of each shift, nurses evaluate overall patient progress and update the plan for the next shift. Upon discharge, a comprehensive evaluation is done to see if the overall goals of care were met and to plan for any ongoing needs after discharge. Evaluation also extends to the quality of nursing care itself. Healthcare institutions often have quality assurance or performance improvement programs that evaluate nursing-sensitive outcomes (such as rates of hospital-acquired pressure ulcers, patient satisfaction, medication error rates, etc.) to assess how well nursing care is delivered. These broader evaluations help in identifying system-level issues and improving nursing practice on a larger scale[openstax.org]. By critically evaluating both individual patient outcomes and aggregate data, nurses can continuously improve their practice and the care environment.

In conclusion, evaluation is the step that determines the effectiveness of the nursing process. It provides closure on the current cycle of care and feeds back into the beginning of a new cycle if needed. Through evaluation, nurses ensure accountability for the care they provide and demonstrate the impact of nursing interventions on patient health. A positive evaluation (goals met) is rewarding and indicates that the nursing care was effective. If evaluation shows areas for improvement, it prompts the nurse to refine their approach. This constant loop of assessment, diagnosis, planning, implementation, and evaluation is what makes nursing care dynamic and responsive to patients’ needs. It embodies the concept of evidence-based practice in nursing – using the best evidence (which includes the patient’s own responses) to guide and adjust care. By mastering all steps of the nursing process, including evaluation, nurses can deliver high-quality, patient-centered care that leads to optimal outcomes.