The Nursing Process

1. Assessment

gather info through SUBjective + OBjective data

SUBject

patient reporting pain

family report

OBservation

lung sounds

vital signs

2. Diagnosis

identify problem to form NANDA approved nursing diagnosis

NO action is taken yet only the problem are being identified

Actual Problem

currently happening

ex. pain after surgery

Potential Problem

could happen

risk what could happen

3. Planning

S pecific
M easurable
A chievable
R relevant
T imely

S pecific

Clearly Identify goal trying to be obtained

M easurable

Create milestones that can be easily be measured

A chievable

Ensure goals set are attainable

R elevant

State why the goal is important

T imely

Create time bound objective for the goal

4. Implementation

put plan into action via nursing interventions

Ex: giving medication
educating patient

5. Evaluation

determine outcomes of goals

evaluate effectiveness of interventions

modify as needed