Nursing Diagnosis - Process

Process

1. Conduct a nursing assessment

   collection of subjective and objective data relevant to the care recipient's (person, family, group, community) human responses to actual or potential health problems / life processes.

2. Cluster and interpret cues/patterns

   Assessment data must be clustered and interpreted before the nurse can plan, implement or evaluate a plan to support patient care

3. Generate Hypotheses

   possible alternatives that could represent the observed cues/patterns.

4. Validation & Prioritization of Nursing Diagnoses

   taking necessary steps to rule out other hypotheses, to confirm with the patient(s) the validity of the hypotheses, and to prioritize the list of diagnoses. A focused assessment may be needed to obtain data for one or more diagnoses

5. Planning

   Determining appropriate (realistic) patient outcomes and interventions most likely to support attainment of those outcomes through evidence-based practice

6. Implementation

Putting the plan of care (nursing diagnoses - outcomes - interventions) into place, preferably in collaboration with the care recipient(s)

1. Evaluation

Movement toward identified outcomes is continually evaluated, with changes made to interventions as necessary. When no positive movement is occurring, reassessment to reevaluate appropriateness of diagnoses and/or achievability of outcomes must occur.