Framework

Nursing Process

The six steps of the nursing process focus on patient care provided by nurses and allied health personnel in clinical practice settings. They are described below:

1. Assessment

Care Components provide the standardized framework classes for documenting, linking, and tracking patient care. A Care Component starts the care process by assessing the patient problems for an episode of care. It is also used to link, map, and code the six steps of the nursing process via encounters or visits, as well as provide the analysis and measures for evidence-based practice. For more information, please visit the Care Components section of this website or the Components Table.

2. Diagnosis

A Nursing Diagnosis is used to identify the specific atomic-level diagnostic conditions based on the patient problems, signs and symptoms, and/or assessed care components that require nursing care. They are selected from the CCC of Nursing Diagnoses. For more information, please visit the Nursing Diagnoses section of this website or the Diagnoses Table.

3. Outcome Identification

Each Nursing Diagnosis requires an Expected Outcome or the anticipated goal of the identified care interventions and actions needed to treat the patients’ conditions. Three qualifiers are written in the present tense to predict care outcomes:

To Improve patient's condition
To Stabilize patient's condition
To Support Deterioration or Death of patient's condition

4. Planning

The Nursing Interventions are atomic-level concepts that represent services identified to develop a plan of care for the patient. They are needed to treat each diagnostic condition and/or patient problem assessed as requiring care. They are selected from the CCC of Nursing Interventions.For more information, please visit the Interventions section of this website or the Interventions Table.

5. Implementation

Each Nursing Intervention requires an Action Type as the major focus for the care. It depicts the specific nursing intervention action. It can provide the measures needed to determine care outcomes, resources, and/or costs. Four qualifiers are used to provide the Action Types:

Monitor/Assess/Observe = Action to monitor the patient condition.
Perform/Direct Care/Provide = Action to perform direct patient care.
Teach/Educate/Instruct = Action to educate patient or caregiver.
Manage/Refer/Contact = Action to manage patient care.

6. Evaluation

Each Nursing Diagnosis requires an Actual Outcome depicting the outcome of care resulting from the interventions and action types used to treat the patient. The same three qualifiers used to predict the Expected Outcomes or care goals are also used to evaluate whether the care outcomes and/or goals were met or not met. Three qualifiers are written in past tense to depict actual outcomes:

Patient’s condition Improved
Patient’s condition Stabilized
Patient’s condition Deteriorated, Died, or Discharged.


Home About Manual Framework - Components - Diagnoses - Interventions Tables Tool Kit Translations References Contact	Framework Introduction Nursing Process Coding Nursing Process The six steps of the nursing process focus on patient care provided by nurses and allied health personnel in clinical practice settings. They are described below: 1. Assessment Care Components provide the standardized framework classes for documenting, linking, and tracking patient care. A Care Component starts the care process by assessing the patient problems for an episode of care. It is also used to link, map, and code the six steps of the nursing process via encounters or visits, as well as provide the analysis and measures for evidence-based practice. For more information, please visit the Care Components section of this website or the Components Table. 2. Diagnosis A Nursing Diagnosis is used to identify the specific atomic-level diagnostic conditions based on the patient problems, signs and symptoms, and/or assessed care components that require nursing care. They are selected from the CCC of Nursing Diagnoses. For more information, please visit the Nursing Diagnoses section of this website or the Diagnoses Table. 3. Outcome Identification Each Nursing Diagnosis requires an Expected Outcome or the anticipated goal of the identified care interventions and actions needed to treat the patients’ conditions. Three qualifiers are written in the present tense to predict care outcomes: To Improve patient's condition To Stabilize patient's condition To Support Deterioration or Death of patient's condition 4. Planning The Nursing Interventions are atomic-level concepts that represent services identified to develop a plan of care for the patient. They are needed to treat each diagnostic condition and/or patient problem assessed as requiring care. They are selected from the CCC of Nursing Interventions.For more information, please visit the Interventions section of this website or the Interventions Table. 5. Implementation Each Nursing Intervention requires an Action Type as the major focus for the care. It depicts the specific nursing intervention action. It can provide the measures needed to determine care outcomes, resources, and/or costs. Four qualifiers are used to provide the Action Types: Monitor/Assess/Observe = Action to monitor the patient condition. Perform/Direct Care/Provide = Action to perform direct patient care. Teach/Educate/Instruct = Action to educate patient or caregiver. Manage/Refer/Contact = Action to manage patient care. 6. Evaluation Each Nursing Diagnosis requires an Actual Outcome depicting the outcome of care resulting from the interventions and action types used to treat the patient. The same three qualifiers used to predict the Expected Outcomes or care goals are also used to evaluate whether the care outcomes and/or goals were met or not met. Three qualifiers are written in past tense to depict actual outcomes: Patient’s condition Improved Patient’s condition Stabilized Patient’s condition Deteriorated, Died, or Discharged.
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