The Nursing Process: Understanding Its Purpose & Steps

Becoming a nurse is a journey filled with learning, growth, challenges, and — most importantly — the opportunity to make a difference in people’s lives.

As with any journey, it’s essential to have a roadmap that will guide you. This is where the nursing process comes in. It serves as the foundation for providing effective and efficient client care.

In this article, we’ll review the nursing process definition and discuss the five main components (or steps) you’ll rely on to help you navigate the nursing field. Here’s what you need to know to succeed in nursing.

What is the Nursing Process?

In 1958, well-known psychiatric health nurse Ida Jean Orlando developed the nursing process, which is now the gold standard because it ensures consistency and quality care.

The process is a client-centered, systematic approach nurses use to deliver the best care.

Purpose of the Nursing Process

The nursing care process is more than just a set of steps.

It’s a philosophy that underpins the entire nursing profession. Its primary purpose is to provide individualized care that meets each client’s needs.

By assessing clients and identifying their needs, nurses can tailor interventions that directly address them, leading to better health outcomes. The nursing process requires nurses to think critically and make clinical decisions at every step.

This enhances the quality of care and empowers nurses to identify and address potential health issues before they escalate. The process can also help nurses stay more organized as they determine the care they’ll provide.

Another purpose of the nursing process is to outline how nurses should act, which can protect them if any legal problems or challenges arise due to the care a client receives following the process.

The Five Steps of the Nursing Process

Here are the five essential nursing process steps:

1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

Each step is integral to ensuring comprehensive and effective client care..

1. Assessment

During the first step of the process, the nurse works to understand the client’s condition and needs.

They’ll do this by collecting various data points, such as the client’s health history, and using their critical thinking skills to collect observations.

The types of nursing assessment data needed to complete this step include:

• Objective data: These include vital signs, weight, pulse, intake, and output

• Objective observations: These include skin color, the ability of the client to make eye contact, how easily they can get out of bed, and the sounds of the lungs.

• Client data points: These subjective data points include the client’s current physical feelings — such as nausea — and emotions like anger or fear.

• Any other useful nonverbal data: This can include the client’s overall appearance and body language.

The nurse can collect the information from primary, secondary, and tertiary sources.

• Primary: The client is the primary source, and the nurse gathers information directly from them.

• Secondary: Family members, friends, and health professionals who have worked with the client can provide secondary sources. Other sources include medical records, test results, and lab reports that can provide more detailed information about a client’s condition.

• Tertiary: Tertiary sources might include textbooks or journals that provide an outside look at data points and data collection.

Carefully record all the data collected for later reference. Check out our Head to Toe Assessment Checklist for details on how to perform a full body assessment.

2. Diagnosis

During the diagnosis part of the nursing process, a nurse combines all the collected data points.

Then, they’ll use their experience, clinical judgment, and expertise to understand how the different points relate to each other so they can provide a nursing diagnosis. This diagnosis articulates the client’s needs and condition.

Sometimes, clients might even need more than one diagnosis. Nurses can consult the current NANDA International (NANDA-I) nursing diagnoses list.

These diagnoses follow Maslow’s Hierarchy of Needs, helping nurses understand how to help clients improve their overall health. Nurses use their diagnosis to guide them through the rest of the nursing process.

3. Planning

During the planning portion of the process, the nurse organizes their thoughts and ideas about the actions they’ll take to treat the client.

This care planning step helps everyone involved in the client’s care know the course of action pursued, the team’s goals for that action, and what they expect to happen for the client.

It’s important to note that planning is an ongoing portion of the nursing process. There is an initial planning stage, conducted immediately after evaluating the client.

Then, there are the ongoing planning stages of the nursing process, which the nurse conducts as they care for the client.

They will need to:

• Watch how the client’s condition changes in response to their care.
• Decide where to focus their attention on a given day.
• Set evolving goals based on the client’s progress.

Finally, when it’s time for the client to leave, the nurse will need to set a discharge plan of care. These plans articulate the support that the client should have as they leave the clinical care setting and explain how the client should coordinate care with other health professionals.

The biggest thing is that the goals set by nurses should be SMART.

A SMART goal is:

• Specific
• Measurable
• Attainable
• Realistic
• Time-oriented

A nurse can quickly evaluate goals that follow these criteria. They need to set long-term goals and short-term goals.

Of course, the nurse should articulate this in an NCP, which explains the care needed and the risk factors the client faces. A well-outlined plan can help ensure good communication between nurses and the client’s health care team members.

4. Implementation

During the implementation stage, the nurse involved in client care puts the plan into action.

Based on the diagnosis and plan outlined in the above steps of the nursing process, the nurse predetermines medical nursing interventions that will help the client achieve their goals. This process often involves informing the client about their care (and why they’re receiving it) so they can better articulate whether the interventions work.

The interventions taken by nurses typically fall under a few different types of classifications:

• Interventions designed to target client behavior: Behavioral interventions help adjust client behavior for better health outcomes, such as helping with stress management or encouraging exercise.

• Interventions that help communities or families: These interventions help the client and those around them. This includes providing HIV education or helping family members better understand their loved one’s illness and how to care for them.

• Interventions to help patients in a clinical setting: Nurses follow interventions to help clients receive the best possible care in the hospital. For example, they might help clients adjust positions to avoid bed sores.

• Interventions to promote safety: Nurses also keep clients safe and free of harm in the clinical care setting. For example, they may create a fall prevention plan or ensure that clients with allergies receive medication without allergic reactions.

• Interventions to help patients physically: Interventions to improve the client’s physical health include inserting an IV or assisting the client with hygiene.

The Nursing Interventions Classification (NIC) publication helps create a standardized process for describing clients’ problems. This can help a nurse easily use the notes produced by other nurses, see the nursing diagnosis, and apply the recommended interventions because everyone has a common vocabulary to work with.

This can aid communication between nurses and provide more consistent care.

Rationales for Nursing Interventions

Nursing rationales provide the reasoning behind specific actions taken in patient care. They are grounded in evidence-based practice and tailored to the patient’s individual needs.

For example, administering medication may be justified by the need to alleviate pain, lower a fever, or combat an infection.

5. Evaluation

Finally, nurses will need to continually monitor and evaluate the success of interventions to ensure that they are effective.

During the evaluation phase, nurses should compare the client outcomes they see with the desired outcomes they identified as goals during the planning stage. This means nurses should regularly reassess clients to determine whether they need to adjust the plan.

Study tip: To help you remember the steps of the nursing process, use the acronym ADPIE (assessment, diagnosis, planning, implementation, and evaluation).

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Nursing Process vs. Nursing Care Plans

While the nursing process and NCPs are closely related, they’re not the same.

The nursing process is the overarching framework that guides nursing practice, while NCPs are specific tools used to document and organize client care. Care plans are a product of the nursing process nurses develop during the planning phase.

They serve as a blueprint for implementing and evaluating client care. By following the nursing process, nurses can create comprehensive, individualized, and effective care plans.

For example, during the assessment phase, a nurse may identify that a client is at risk for falls. This finding will lead to a nursing diagnosis of “risk for falls,” which will then inform the development of a care plan focused on fall prevention.

The nurse will implement interventions such as:

• Placing the client in a room near the nurses’ station
• Providing assistive devices
• Educating the client on safety measures

The evaluation phase involves assessing whether these interventions effectively reduced the client’s fall risk.

Check out our free template for writing an effective care plan to guide you in developing your care plans.

The Nursing Process in Different Settings

The nursing process is versatile, and nurses can apply them in various clinical settings, including hospitals, long-term care facilities, and community health environments.

However, how a nurse implements the process depends on the setting and the client population.

Hospitals

In hospital settings, nurses often use the nursing process to address acute health issues.

For example, an intensive care unit (ICU) nurse may focus on managing life-threatening conditions—such as respiratory failure or sepsis—using the nursing process to guide their interventions.

Long-term care

In long-term care settings, nurses use the nursing process to manage chronic conditions and promote quality of life.

Nurses may focus on preventing complications, such as pressure ulcers (bedsores) or malnutrition, by using the nursing process to identify risk factors and implement preventive measures.

Community Health

In community health settings, nurses use the nursing process to address public health issues, such as disease prevention and health promotion.

Nurses may use the process to develop and implement community-based interventions, such as vaccination campaigns or health education programs.

Common Challenges in Applying the Nursing Process

Despite its effectiveness, the nursing process has its challenges.

Nurses may encounter obstacles that make it difficult to follow the process as intended. But with the right strategies, they can overcome these challenges.

High nurse-to-patient ratios, limited resources, and time constraints

One of the most common challenges nurses face in applying the nursing process is high nurse-to-patient ratios.

With limited time and resources, nurses may struggle to complete all steps of the process for each client. To address this challenge, nurses can prioritize tasks, delegate responsibilities, and use time-saving tools like electronic health records (EHRs).

Limited communication and collaboration among health care team members

The nursing process requires effective communication and collaboration among health care team members.

However, it’s not always easy to achieve this, especially in fast-paced and high-stress environments.

To overcome this challenge, nurses can:

• Use communication tools like SBAR (situation, background, assessment, recommendation)
• Attend regular team meetings
• Document client information accurately and thoroughly

Insufficient knowledge or skills

Another challenge nurses may face is a lack of knowledge or skills related to specific steps of the nursing process.

Nurses can overcome this challenge by:

• Seeking more education or training
• Consulting with more experienced colleagues
• Using evidence-based resources.

Continuous learning is essential for nurses to improve their practice and apply the nursing process effectively.

Lack of client involvement

Client involvement ensures that clients receive holistic care that meets their needs and preferences.

However, clients may not always fully engage or participate in their care.

To address this challenge, nurses can:

• Actively involve clients in setting goals and making decisions.
• Educate clients about their condition and treatment options.
• Encourage open communication.

Involving patients in their care empowers them to take an active role in their health and can improve outcomes.

The Future of the Nursing Process

As technology advances, nurses will have access to more tools and data, allowing them to make even more informed decisions when implementing the nursing process.

EHRs, for example, streamline the documentation and communication of client data, making it easier for nurses to follow the process. Additionally, telehealth and remote monitoring technologies expand the reach of nursing care, allowing nurses to assess or manage clients in real time, regardless of their location.

Evidence-based practice is another trend shaping the future of the nursing process. By integrating the latest research findings into their practice, nurses can ensure they base their interventions on the best available evidence.

This improves the quality of care and client outcomes.

Nurses must be committed to lifelong learning to stay current with technological advancements and evidence-based practice. Continuing education, attending conferences and workshops, and pursuing advanced degrees are all ways for nurses to enhance their knowledge and skills.

Trust the Process with SimpleNursing

The nursing process is a systematic approach to providing high-quality care that’s essential for all nurses to master.

From assessment and diagnosis to implementation and evaluation, each step is important in promoting positive client outcomes. Through collaboration, ongoing education, and staying abreast of emerging trends, nurses can ensure they’re using the nursing process effectively now and in the future.

At SimpleNursing, we understand the importance of mastering the nursing process. That’s why our platform provides comprehensive resources and tools to help you succeed.

These resources include:

• Animated videos
• Courses
• Practice questions
• Study guides
• and more…

Trust the process with SimpleNursing as you continue your journey toward becoming a competent and confident nurse. Join our nursing school membership and take the first step.