In which step of the nursing process does the nurse analyze data and identify client problems?
A. Assessment
B. Diagnosis
C. Planning outcomes
D. Evaluation
Correct Answer: B. Diagnosis
In the diagnosis phase, the nurse identifies the client’s health status. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community.
Option A: In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
Option C: In the planning outcomes phase, the nurse formulates goals and outcomes. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum.
Option D: In the evaluation phase, which occurs after implementing interventions, the nurse gathers data about the client’s responses to nursing care to determine whether client outcomes were met. This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.