ASSESSMENT
The systematic and continuous collection, organization, validation, and documentation of data or information. There are four different types of assessment – initial assessment, problem-focused assessment, emergency assessment, and time-lapsed assessment. It includes the clients perceived needs, health problems, related experience, health practices, values and lifestyles.
DIAGNOSIS
The phase when nurses refers to the reasoning process and use critical thinking skills to interpret assessment data and identify client’s strengths and health problems, and formulates diagnostic statements.
PLANNING
This is a deliberative, systematic phase of the nursing process that involves decision making and problem solving. The nurse and client develop client goals/desired outcomes and nursing interventions to prevent, reduce, or alleviate the client’s problems.
IMPLEMENTATION
The phase in which the nurse is normally reassessing the client, determining the nurse’s need for assistance, implementing the nursing interventions, supervising the delegated care and documenting nursing activities.
EVALUATION
This is a planned, ongoing, purposeful activity in which clients and health care professionals determine the client’s progress toward achievement of goals, outcomes and the effectiveness of the nursing care plan. It is an important aspect of the nursing process because conclusions drawn from the evaluation whether the nursing interventions should be terminated, continued, or changed.