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The fourth step in the nursing process is implementation. Implementation involves the execution of the nursing plan of care derived during the planning phase. It consists of performing nursing activities that have been planned to meet the goals set with the client. Nurses may delegate some of the nursing interventions to other persons assigned to care for the client—for example, the licensed practical nurses and unlicensed assistive personnel.
Implementation involves many skills. The nurse must continue to assess the client’s condition before, during, and after the nursing intervention. Assessment prior to the intervention provides the nurse with baseline data. Assessment during and after the intervention allows the nurse to detect positive or negative responses the client may have to the intervention. If negative responses occur during the procedure, the nurse must take appropriate action. If positive responses occur, the nurse adds this information to the database for use in evaluating the efficacy of the intervention. The nurse must also possess psychomotor skills, interpersonal skills, and critical thinking skills to perform the nursing interventions that have been planned. The nurse uses psychomotor skills when performing procedures such as giving injections, changing dressings, and helping the client perform range-of-motion (ROM) exercises. Interpersonal skills are necessary as the nurse interacts with the client and the family to collect data, provide information in teaching sessions, and offer support in times of anxiety. Critical thinking skills enable the nurse to think through the situation, ask the appropriate questions, and make decisions about what needs to be done. The implementation step also involves reporting and documentation. Data to be recorded include the client condition prior to the intervention, the specific intervention performed, the client response to the intervention, and client outcomes.
Evaluation
Evaluation, the fifth step in the nursing process, involves determining whether the client goals have been met, partially met, or not met. If the goal has been met, the nurse must then decide whether nursing activities will cease or continue in order for status to be maintained. If the goal has been partially met or not been met, the nurse must reassess the situation. Data are collected to determine why the goal has not been achieved and what
modifications to the plan of care are necessary. There are a number of possible reasons that goals are not met or are only partially met, including:
• The initial assessment data were incomplete.
• The goals and expected outcomes were not realistic.
• The time frame was too optimistic.
• The goals and/or the nursing interventions planned were not appropriate for the client.
Evaluation is an ongoing process. Nurses continually evaluate data in order to make informed decisions during other phases of the nursing process.

Planning is the third step of the nursing process and includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care. Once the nursing diagnoses have been developed and client strengths have been identified, planning can begin. The planning phase involves several tasks:
• The list of nursing diagnoses is prioritized.
• Client-centered long- and short-term goals and outcomes are identified and written.
• Specific interventions are developed.
• The entire plan of care is recorded in the client’s record. (continue reading…)

Analysis of the collected data leads the nurse to make a diagnosis in one of the following categories:
• Actual problems
• Potential problems (including those where risk factors exist and there are possible problems)
• Wellness conditions
• Collaborative problems
An actual nursing diagnosis indicates that a problem exists, and is composed of the diagnostic label, related factors, and signs and symptoms. An example of an actual diagnosis is: Impaired Skin Integrity related to prolonged pressure on bony prominence as manifested by (AMB) Stage II pressure ulcer over coccyx, 3 cm in diameter.
A risk nursing diagnosis (potential problem) indicates that a problem does not yet exist, but special risk factors are present. A risk diagnosis is composed of the diagnostic label preceded by the phrase “risk for,” with the specific risk factors listed. An example of a risk diagnosis is: Risk for Impaired Skin Integrity related to inability to turn self from side to side in bed. (continue reading…)