The nursing process is the systematic, client-centered, problem-solving method nurses use to deliver and evaluate care. It is cyclical and continuous: new data at any point can send the nurse back to an earlier step. Clinical judgment drives each step. The NCSBN Clinical Judgment Measurement Model, used in current US licensure testing, describes it in six steps: recognize cues → analyze cues → prioritize hypotheses → generate solutions → take action → evaluate outcomes.

Steps (ADPIE)

1. Assessment — collect, validate, organize, and document data
2. Diagnosis — analyze data to identify actual and potential health problems (nursing diagnoses)
3. Planning — set priorities, write measurable outcomes, choose interventions (the ANA standards list outcomes identification as a separate step before planning)
4. Implementation — carry out, delegate, and document interventions
5. Evaluation — compare client responses with the expected outcomes and revise the plan

Documentation turns the process into a permanent legal record, and handoff communication transfers responsibility for the client safely between caregivers. Communication failures during handoffs are a leading contributor to serious adverse events.

Types of data

Types of assessment

• Comprehensive (initial, on admission) — baseline of all systems
• Focused (problem-oriented) — about a specific problem, e.g., pain reassessment
• Emergency — rapid ABC assessment in life-threatening situations
• Time-lapsed — comparing current status with baseline after an interval

Methods: interview, observation, physical examination (inspection, palpation, percussion, auscultation; abdomen: inspect, auscultate, then percuss and palpate).

Validation — double-check data that are inconsistent or unusual (e.g., recheck a very high blood pressure manually with the correct cuff size). Cluster related cues to find patterns. Document assessment findings objectively, using the client's own words in quotation marks for subjective data.

Nursing diagnosis is a clinical judgment about a human response to health problems or life processes that nurses can treat independently. It differs from a medical diagnosis, which identifies disease and stays the same as long as the disease is present.

NANDA International (NANDA-I) diagnosis types

• Problem-focused (actual): written in PES format — Problem (diagnostic label) + Etiology ("related to") + Signs and symptoms ("as evidenced by")
  • Example: Acute pain related to surgical incision as evidenced by pain rating of 7 out of 10, guarding, and grimacing
• Risk: problem + risk factors; no signs yet (e.g., Risk for infection as evidenced by invasive urinary catheter; older texts use "related to")
• Health promotion: readiness to enhance well-being (e.g., Readiness for enhanced nutrition)
• Syndrome: a cluster of diagnoses occurring together

Common errors: using a medical diagnosis as the etiology ("related to pneumonia" — use the nursing-treatable cause, such as thick secretions), writing a need or an intervention instead of a response, including legally risky or judgmental statements, and making the problem and etiology say the same thing. Interdisciplinary teams also address collaborative problems (potential complications such as hemorrhage) that nurses monitor and manage with other providers.

Priority setting

1. Airway, breathing, circulation (ABCs) and immediate life threats
2. Maslow's hierarchy: physiologic needs → safety and security → love and belonging → esteem → self-actualization
3. Actual (acute) problems before potential (risk) problems — but a high-risk potential problem (e.g., risk for aspiration during feeding) may take priority over a minor actual one
4. Acute and unstable before chronic and stable; client's own priorities count when not life-threatening

Outcomes (goals) are client-centered and SMART: Specific, Measurable, Achievable, Relevant, Time-bound. Format: subject + action verb + condition + criterion + time frame.

• Good: "Client will walk 30 m (100 ft) in the hallway with a walker twice a day by the third postoperative day"
• Poor: "Client will understand diabetes" (not measurable — use "state," "demonstrate," "list")
• Short-term goals (hours to about a week); long-term goals (weeks to months, often beyond discharge)
• Standardized language: Nursing Outcomes Classification (NOC) and Nursing Interventions Classification (NIC)

Types of interventions

Listed in priority order.

1. Implementation
   • Reassess the client before acting — the plan may no longer fit (e.g., hold ambulation if the client is now hypotensive)
   • Perform interventions safely, evaluate the immediate response, and document after they are done
   • Delegation uses the five rights of delegation: right task, right circumstance, right person, right direction and communication, right supervision and evaluation. Registered nurses do not delegate assessment, planning, evaluation, teaching that requires judgment, or care of unstable clients; they remain accountable for delegated tasks
2. Evaluation
   • Compare the client's actual response with each outcome: met, partially met, or not met
   • If not met, ask why — incomplete data, wrong diagnosis, unrealistic goal, ineffective intervention — then revise, continue, or discontinue the plan
3. Documentation principles
   • Accurate, factual, objective: describe what was seen, heard, measured ("client crying, states 'I miss my wife'") — avoid labels ("uncooperative," "drunk") and vague terms ("good," "adequate," "appears")
   • Timely: chart as soon as possible after care; never before care is given; include date and time
   • Complete and concise: assessment, interventions, client response, teaching, communication with providers (who was notified, when, what was said, what was ordered)
   • Chart only your own care; never document for someone else
   • Late entries are labeled "late entry" with the current date and time and the time the event occurred
   • Errors: in electronic records, follow the amendment process; on paper, draw a single line through the error, write "error" (or "mistaken entry") with date, time, and initials — never erase, use correction fluid, or obliterate
   • Do not leave blank spaces; sign with legal name and credentials
   • Do not mention an incident report in the client's chart; document the facts of the event and care given
   • Use only approved abbreviations; avoid "Do Not Use" abbreviations
4. Documentation formats

1. Confidentiality and privacy: access only records of clients in your care; share the minimum necessary; log out of workstations; never discuss clients in public areas or on social media; do not photograph clients without consent and policy
2. Handoff communication
   • Use a standardized tool:
     • SBAR — Situation (what is happening now), Background (relevant history, diagnosis, current treatment), Assessment (the nurse's analysis of the problem), Recommendation or request (what is needed and when)
     • I-PASS — Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver
   • Bedside handoff with the client (and family) involved when appropriate — allows joint safety checks (lines, pumps, wristband, environment)
   • Face-to-face with opportunity to ask questions; minimize interruptions
   • Receiver reads back or summarizes critical information (closed-loop communication)
   • Include pending tests, recent changes, code status, allergies, safety risks (falls, isolation, suicide risk), and what to watch for
3. Communicating with providers
   • Verbal and telephone orders: write down the order and read it back for confirmation; limit to urgent situations; the prescriber signs within policy time frames
   • Critical test results: report promptly to the responsible provider, document who was notified and when, and read back values
   • Speak up when concerned — escalate through the chain of command; TeamSTEPPS tools include CUS ("I am Concerned, I am Uncomfortable, this is a Safety issue") and the two-challenge rule

• Involve the client and family in setting goals — outcomes they value are more achievable
• Explain what the nurse is documenting and that clients have a right to access their records
• At discharge, give written instructions in plain language; use teach-back to check understanding
• Invite clients to participate in bedside handoff and to speak up about errors or concerns

• Nursing process: Assessment → Diagnosis → Planning → Implementation → Evaluation — cyclical
• Subjective = what the client says; objective = what is observed or measured
• Validate unexpected data before acting on them
• PES: Problem + "related to" etiology + "as evidenced by" signs; no medical diagnosis as the etiology
• Risk diagnoses have no signs yet
• Priorities: ABCs, then Maslow, actual before potential (unless the risk is serious)
• Outcomes are client-centered and SMART (measurable verbs, time frame)
• Independent vs dependent vs collaborative interventions
• Reassess before implementing; never delegate assessment, planning, evaluation, or unstable clients
• Chart after care, objectively; late entries labeled; single-line correction, never erase
• SBAR: Situation, Background, Assessment, Recommendation; bedside handoff with read-back
• Verbal and telephone orders and critical results: write down and read back