Assessment

 First nursing process step

 Requires critical thinking skills and collects subjective and objective
data
 Subjective data
o Verbal statements
o Recounts from the patient/ primary caregiver regarding their
current complain
o Past medical history
o Medications
 Objective data
o Measurable
o Tangible data
 Such as vital signs
 Intake and output of fluids
 Height, and weight
o Electronic health records may also assist
Diagnosis
 Employing clinical judgment assists in planning the consecutive steps in
patient care
o Actual or potential health problems  to help prioritize and
plan care
 Helps prioritize and plan care and encompasses Maslow's Hierarchy of
Needs
Planning
 Goals and outcomes are formulated, according to current evidence-based
practice (EBP) guidelines, that directly impact patient care
 Always patient-centered to achieve a positive patient outcome
 Essential as they provide personalized care tailored to an individual's
unique needs
Implementation
 Which is the step that involves the actual carrying out of interventions
outlined by the plan of care
 Requires interventions
o Such as applying a cardiac monitor or oxygen,
o Medication administration,
o Standard treatment protocols
Evaluation
 Final step of the nursing process
 Vital to a positive outcome
 When healthcare providers intervene or implement care, they must
evaluate their implementation to ensure the desired outcome has been met