American Nurses Association Standards of Practice*
The registered nurse collects comprehensive data pertinent to the patient’s health or the situation.
• Collects data in a systematic and ongoing process.
• Involves the patient, family, other healthcare providers, and environment, as appropriate, in holistic data collection.
• Prioritizes data collection activities based on the patient’s immediate condition, or anticipated needs of the patient or situation.
• Uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data.
• Uses analytical models and problem-solving tools.
• Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances.
The registered nurse analyzes the assessment data to determine the diagnoses or issues.
The registered nurse identifies expected outcomes for a plan individualized to the patient or the situation.
• Involves the patient, family, and other healthcare providers in formulating expected outcomes when possible and appropriate.
• Derives culturally appropriate expected outcomes from the diagnoses.
• Considers associated risks, benefits, costs, current scientific evidence, and clinical expertise when formulating expected outcomes.
• Defines expected outcomes in terms of the patient, patient values, ethical considerations, environment, or situation with such consideration as associated risks, benefits and costs, and current scientific evidence.
• Includes a time estimate for attainment of expected outcomes.
• Develops expected outcomes that provide direction for continuity of care.
• Modifies expected outcomes based on changes in the status of the patient or evaluation of the situation.
The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.
• Develops an individualized plan considering patient characteristics or the situation (e.g., age and culturally appropriate, environmentally sensitive).
• Develops the plan in conjunction with the patient, family, and others, as appropriate.
• Includes strategies within the plan that address each of the identified nursing diagnoses or issues, which may include strategies for promotion and restoration of health and prevention of illness, injury, and disease.
• Provides for continuity within the plan.
• Incorporates an implementation pathway or timeline within the plan.
• Establishes the plan priorities with the patient, family, and others as appropriate.
• Utilizes the plan to provide direction to other members of the healthcare team.
• Defines the plan to reflect current statutes, rules and regulations, and standards.
• Integrates current trends and research affecting care in the planning process.
• Considers the economic impact of the plan.
• Uses standardized language or recognized terminology to document the plan.
The registered nurse implements the identified plan.
• Implements the plan in a safe and timely manner.
• Documents implementation and any modifications, including changes or omissions, of the identified plan.
• Utilizes evidence-based interventions and treatments specific to the diagnosis or problem.
• Utilizes community resources and systems to implement the plan.
• Collaborates with nursing colleagues and others to implement the plan.
The registered nurse employs strategies to promote health and a safe environment.
• Provides health teaching that addresses such topics as healthy lifestyles, risk-reducing behaviors, developmental needs, activities of daily living, and preventive self-care.
• Uses health promotion and health teaching methods appropriate to the situation and the patient’s developmental level, learning needs, readiness, ability to learn, language preference, and culture.
• Seeks opportunities for feedback and evaluation of the effectiveness of the strategies used.
The registered nurse evaluates progress toward attainment of outcomes.
• Conducts a systematic, ongoing, and criterion-based evaluation of the outcomes in relation to the structures and processes prescribed by the plan and the indicated timeline.
• Includes the patient and others involved in the care or situation in the evaluative process.
• Evaluates the effectiveness of the planned strategies in relation to patient responses and the attainment of the expected outcomes.
• Documents the results of the evaluation.
• Uses ongoing assessment data to revise the diagnoses, outcomes, the plan, and the implementation as needed.
• Disseminates the results to the patient and others involved in the care or situation, as appropriate, in accordance with state and federal laws and regulations.
*Adapted with permission from American Nurses Association, Nursing: Scope and Standards of Practice, © 2004 nursesbooks.org, Silver Spring, MD.