The first stage of the NP is the assessment stage. Potter and Perry et al (2017) define assessment as the deliberate and systematic collection of information about a patient to determine his or …show more content…
A nursing diagnosis is a clinical judgment about an individual, family or community responses to actual and potential health problems. The data collected by the nurse during the assessment stage is used to draw diagnostic conclusions which encompass problems that will be treated by the nurse as well as problems requiring collaborative efforts with other disciplines. The nursing diagnostic process includes three decision making steps which include clustering, identifying health problems and formulating a diagnosis. Data clusters are patterns of signs, symptoms, and or risk factors gathered during the assessment, that are logically grouped together and contain defining characteristics that are both observable and verifiable. Once information has been clustered, the nurse will interpret the data by selecting a specific diagnosis listed in the NANDAI that applies to the patient. To make the nursing diagnosis specific to the patient, the nurse needs to provide context to the diagnosis by selecting the most relevant related to factor. Potter and Perry define related factor as “a condition, historical factor or etiology that gives context for the defining characteristics and shows the type of relationship with the nursing diagnosis.” The etiology of the nursing diagnosis is in the sphere of nursing practice and should not change the medical …show more content…
Because the patient’s condition does not remain static, the nurse is required to kick off the implementation stage by reassessing the patient to check if the proposed interventions remain the most appropriate and revising the existing care plan if need be. The nurse will then organize the required resources such as personnel, equipment, and environmental availability and suitability. In addition to this, the nurse will ensure that the patient is comfortable and able to participate. To successfully implement the interventions, the nurse utilizes his or her cognitive, interpersonal and psychomotor skills to ensure professional delivery of compassionate and skilled care. The final stage of the NP is the evaluation stage. During this stage, the nurse assesses whether expected outcomes resulting in the improvement of the patient’s condition. Evaluation is a continuous process which occurs whenever the nurse is in contact with the patient. The nurse goes on to make clinical decisions based on subjective and objective information regarding the patient’s response to care. These findings determine if set goals have been met, in which case the care plan can be retired, or if the nurse needs to adjust the care plan if the expected outcome has not been