Assessment Phase: The first step involves a thorough assessment of the patient’s health status. This includes collecting medical history, conducting physical examinations, and obtaining diagnostic test results. Diagnosis: Based on the assessment, the nurse collaborates with other healthcare professionals to determine the patient's health problems. This step involves critical thinking and clinical judgment. Setting Goals: Establishing measurable and achievable goals is essential. These goals should be specific, measurable, attainable, relevant, and time-bound (SMART). Planning Interventions: This involves selecting evidence-based interventions that are most likely to help achieve the set goals. Interventions can range from medication administration, physical therapy, to lifestyle modifications. Implementation: Carrying out the planned interventions while continuously monitoring the patient’s response. Documentation of each step is crucial for continuity of care and legal purposes. Evaluation: Regularly evaluating the patient's progress towards the goals. If the desired outcomes are not met, revisiting and adjusting the treatment plan is necessary.
