Nursing Diagnosis - Process

Process

This section's factual accuracy is disputed.
  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.

Read more about this topic:  Nursing Diagnosis

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