OSCE [Objective structured clinical examination]

An objective structured clinical examination (OSCE) is an approach to the assessment of clinical

competence in which the components are assessed in a planned or structured way with attention
being paid to the objectivity of the examination which is basically an organization framework
consisting of multiple stations around which students rotate and at which students perform and are
assessed on specific tasks. OSCE is a modern type of examination often used for assessment in health
care disciplines.

History and purpose

The development of OSCE is credited to Ronald Harden. Since the publication of the first paper in
the British Medical Journal in 1975, OSCE has been widely adopted in many medical schools and
professional bodies. The format of OSCE is continuously evolving and may include real or simulated
patients, clinical specimens, and other clinical materials. OSCE is primarily used to assess focused
clinical skills such as history taking, physical examination, diagnosis, communication, and counseling.

In the last three decades the OSCE has seen a steady exponential growth and usage in both
undergraduate and postgraduate examinations around the globe. OSCEs are also used for licensure
examinations and as a feedback tool in formative settings. Common uses of the OSCE include:

 as a performance based assessment tool for testing the minimum accepted standards of
students or trainees as barrier (exit) examinations during the undergraduate years in most of
the medical schools

 as a postgraduate high stakes assessment tool in Royal College examinations

 as a formative assessment tool in undergraduate medical education

 as a tool for the assessment of graduates seeking highstakes licensure and certification to
practise medicine

 as an educational tool to provide immediate feedback

Objective structured clinical examinations evaluate learners "showing how" to perform complex
clinical tasks including those infrequently observed and those core to practice.

Design

An OSCE usually consists of a circuit of short stations, usually 5–10 minutes, though some use up to
15 minutes. In each station, the candidate is examined on a one-to-one basis with one or two
examiner(s) and either real or simulated (actors or electronic patient simulators) patients. Each
station has a different examiner, as opposed to the traditional method of clinical examinations
where a candidate would be assigned to one examiner for the entire examination. Candidates rotate
through the stations, completing all the stations on their circuit. In this way, all candidates take the
same stations. It is considered to be an improvement over traditional examination methods because
the stations can be standardised, enabling fairer peer comparison and complex procedures can be
assessed without endangering patients health.

OSCEs are designed to assess candidates' clinical skills more objectively. This is done by giving all
candidates the same stations (though signs of real patients may vary slightly), where they are
assessed with the same marking scheme and awarded marks for each step performed correctly. If
theoretical knowledge is examined, such as with the examiner asking questions at the end of the
station, the questions will also be standardised. The candidate will only be asked questions on the
marking scheme, and will not be awarded marks for any other questions asked.

OSCEs are also designed to be structured, with instructions carefully written to ensure that the
candidate has a very specific task to complete in each station. Where simulated patients are used,
detailed scripts are provided to ensure that the information provided is the same for all candidates,
even including the emotions displayed by the patient. The examination is carefully structured to
include parts from all elements of the curriculum as well as a wide range of skills.

Variation
There are several variations of OSCE, those are:

 Objective Structured Practical Examination (OSPE), which assess practical skills, knowledge
and/or interpretation of data in non clinical settings.

 Objective Structured Assessment of Technical Skills (OSATS), which designed for objective
skills assessment, consisting of a global rating scale and a procedure specific checklist. It is
primarily used for feedback or measuring progress of training in surgical specialities.

 Objective Structured Video Examinations (OSVE). The variation consists of videotaped

recordings of patient-doctor encounters are shown to students simultaneously and
questions related to the video clip are asked. Written answers are marked in a standardised
manner.

 Team Objective Structured Clinical Examination (TOSCE). Formative assessment covering

common consultations in general practice. A team of students visits each station in a group,
performing one task each in a sequence. The candidates are marked for their performance
and feedback is provided. The team approach improves efficiency and encourages learning
from peers.

Advantages
The advantages of OSCE are:

 Broader content coverage: Unlike the conventional short or long case examination format,
multi-station OSCE allows broader content and domain coverage.

 Decreased bias: Student performance in each station is marked by independent examiners

on a predetermined marking template that is customized to each patient scenario, thus
reduces the variability of examination.
  Practicability: OSCE allows the use of simulated patients and clinical materials, thereby
decreasing the need for real patients during the examination.

Disadvantages
The disadvantages of OSCE are:

 Fragmentation of tasks: OSCE is often criticized for fragmenting a physician’s task as the
candidates are asked to focus on a particular task, thus potentially undermines what a
physician is expected to do in real life.

 Construct invalidity: OSCE is based on a predefined list of activities that a candidate is

required to perform during the examination. However, this may not be a true reflection of
how a competent and experienced physician works in real life.

 Preparation time and budget: The preparation time for simulated patient (SP)-based OSCE is
longer, as it includes script writing, training, and pilot testing. It may take several sessions for
an SP to become familiar with the case and realistically portray the findings in a consistent
manner. The increased budget needed to run a successful SP program is also a valid concern.

Marking
Marking in OSCEs is done by the examiner. Occasionally written stations, for example, writing a
prescription chart, are used and these are marked like written examinations, again usually using a
standardized mark sheet. One of the ways an OSCE is made objective is by having a detailed mark
scheme and standard set of questions. For example, a station concerning the demonstration to a
simulated patient on how to use a metered dose inhaler (MDI) would award points for specific
actions which are performed safely and accurately. The examiner can often vary the marks
depending on how well the candidate performed the step. At the end of the mark sheet, the
examiner often has a small number of marks that they can use to weight the station depending on
performance and if a simulated patient is used, then they are often asked to add marks depending
on the candidates approach. At the end, the examiner is often asked to give a "global score". This is
usually used as a subjective score based on the candidates overall performance, not taking into
account how many marks the candidate scored. The examiner is usually asked to rate the candidate
as pass/borderline/fail or sometimes as excellent/good/pass/borderline/fail. This is then used to
determine the individual pass mark for the station.

Many centres allocate each station an individual pass mark. The sum of the pass marks of all the
stations determines the overall pass mark for the OSCE. Many centres also impose a minimum
number of stations required to pass which ensures that a consistently poor performance is not
compensated by a good performance on a small number of stations.

There are, however, criticisms that the OSCE stations can never be truly standardized and objective
in the same way as a written exam. It has been known for different patients / actors to afford more
assistance, and for different marking criteria to be applied. Finally, it is not uncommon at certain
institutions for members of teaching staff be known to students (and vice versa) as the examiner.
This familiarity does not necessarily affect the integrity of the examination process, although there is
a deviation from anonymous marking. However, in OSCEs that use several circuits of the same
stations the marking is repeatedly shown to be very consistent which supports the validity that the
OSCE is a fair clinical examination. There are arguments for and against quarantining OSCE
examinees to prevent sharing of exam information. Although the data tend to show no
improvement in the overall scores in a later OSCE session, the research methodology is flawed and
validity of the claim is questionable. A study suggested that marks do not give a sound inference of
student collusion in an OSCE.

Preparation
Preparing for OSCEs is very different from preparing for an examination on theory. In an OSCE,
clinical skills are tested rather than pure theoretical knowledge. It is essential to learn correct clinical
methods, and then practice repeatedly until one perfects the methods whilst simultaneously
developing an understanding of the underlying theory behind the methods used.Marks are awarded
for each step in the method; hence, it is essential to dissect the method into its individual steps,
learn the steps, and then learn to perform the steps in a sequence.

Most hospitals and universities have clinical skills labs where students have the opportunity to
practice clinical skills such as taking blood or mobilizing patients in a safe and controlled
environment. It is often very helpful to practise in small groups with colleagues, setting a typical
OSCE scenario and timing it with one person role playing a patient, one person doing the task and if
possible, one person either observing and commenting on technique or even role playing the
examiner using a sample mark sheet. Many OSCE textbooks have sample OSCE stations and mark
sheets that can be helpful when studying in the manner. In doing this the candidate is able to get a
feel of running to time and working under pressure.

In many OSCEs the stations are extended using data interpretation. For example, the candidate may
have to take a brief history of chest pain and then interpret an electrocardiogram. It is also common
to be asked for a differential diagnosis, to suggest which medical investigations the candidate would
like to do or to suggest a management plan for the patient.

The peer-assisted mock OSCE improved tutee confidence, reduced the anxieties associated with
OSCEs, and improved candidate confidence for OSCE.

See also
 Health assessment

 Multiple mini-interview

HEALTH ASSESSMENT
Health assessment is a plan of care that identifies the specific needs of a person and how
those needs will be addressed by the healthcare system or skilled nursing facility. Health
assessment is the evaluation of the health status by performing a physical exam after taking
a health history. It is done to detect diseases early in people that may look and feel well.
Evidence does not support routine health assessments in otherwise healthy people.[1]
Health assessment is the evaluation of the health status of an individual along the health
continuum.[2] The purpose of the assessment is to establish where on the health continuum
the individual is because this guides how to approach and treat the individual. The health
care approaches range from preventive, to treatment, to palliative care in relation to the
individual's status on the health continuum. It is not the treatment or treatment plan. The
plan related to findings is a care plan which is preceded by the specialty such as
medical, physical therapy, nursing, etc.

Corporate health assessments

Research by Data Bridge Market Research shows that the market for corporate health
assessments which was USD 2,91,272.4 million in 2023, is likely to reach USD 8,23,374.65
million by 2031 and is expected to undergo a CAGR of 12.5% during the forecast period.
Healthcare providers such as Bupa and Nuffield now routinely offer health assessments to
individuals and corporate clients, building on the growing market for these services.
Definitions of health assessment are varied, with some using the term health assessment
and health checks interchangeably.
UK healthcare provider Verve Healthcare makes a clear difference:
 A staff health check is a routine examination conducted by a health professional to
assess an individual's overall health status. The primary aim is to identify health
issues early, to monitor ongoing health conditions and to monitor future health risks.
 Health assessments are more detailed than regular health checks. They provide a
holistic view of an individual's health and can identify underlying health conditions.

History
Health assessment has been separated by authors from physical assessment to include the
focus on health occurring on a continuum as a fundamental teaching. In the healthcare
industry it is understood health occurs on a continuum, so the term used is assessment but
may be preference by the speciality's focus such as nursing, physical therapy, etc. In
healthcare, the assessment's focus is biopsychosocial but the intensity of focus may vary by
the type of healthcare practitioner. For example, in the emergency room the focus is chief
complaint and how to help that person related to the perceived problem. If the problem is a
heart attack then the intensity of focus is on the biological/physical problem initially.
Nursing assessment

Nursing assessment is the gathering of information about

a patient's physiological, psychological, sociological, and spiritual status by a
licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A
section of the nursing assessment may be delegated to certified nurses aides. Vitals and
EKG's] may be delegated to certified nurses aides or nursing techs. (Nurse Journal, 2017 it
differs from a medical diagnosis. In some instances, the nursing assessment is very broad in
scope and in other cases it may focus on one body system or mental health. Nursing
assessment is used to identify current and future patient care needs. It incorporates the
recognition of normal versus abnormal body physiology. Prompt recognition of pertinent
changes along with the skill of critical thinking allows the nurse to identify
and prioritize appropriate interventions. An assessment format may already be in place to
be used at specific facilities and in specific circumstances.
The client interview

Nursing process
Before assessment can begin the nurse must establish a professional and therapeutic mode
of communication. This develops rapport and lays the foundation of a trusting, non-
judgmental relationship. This will also assure that the person will be as comfortable as
possible when revealing personal information. A common method of initiating therapeutic
communication by the nurse is to have the nurse introduce herself or himself. The interview
proceeds to asking the client how they wish to be addressed and the general nature of the
topics that will be included in the interview.
The therapeutic communication methods of nursing assessment takes into account
developmental stage (toddler vs. the elderly), privacy, distractions, and age-related
impediments to communication such as sensory deficits and language, place, time, non-
verbal cues. Therapeutic communication is also facilitated by avoiding the use of medical
jargon and instead using common terms used by the patient.
During the first part of the personal interview, the nurse carries out an analysis of the
patient needs. In many cases, the client requires a focused assessment rather than a
comprehensive nursing assessment of the entire bodily systems. In the focused assessment,
the major complaint is assessed. The nurse may employ the use of acronyms performing the
assessment:
 OLDCART
  Onset of health concern or complaint
 Location of pain or other symptoms related to the area of the body involved
 Duration of health concern or complaint
 Characteristics
 Aggravating factors or what makes the concern or complaint worse
 Relieving factors or what makes the concern or complaint better
 Treatments or what treatments were tried in the past or ongoing
Patient history and interview

Auscultatory method aneroid sphygmomanometer with

stethoscope
The patient history and interview is considered to be subjective but still of high importance
when combined with objective measurements. High quality interviewing strategies include
the use of open-ended questions. Open-ended questions are those that cannot be answered
with a simple "yes" or "no" response. If the person is unable to respond, then family or
caregivers will be given the opportunity to answer the questions.
The typical nursing assessment in the clinical setting will be the collection of data about the
following:
 present complaint and nature of symptoms
 onset of symptoms
 severity of symptoms
 classifying symptoms as acute or chronic
 health history
 family history
 social history
 current medical and/or nursing management
 understanding of medical and nursing plans
  perception of illness
In addition, the nursing assessment may include reviewing the results of laboratory values
such as blood work and urine analysis. Medical records of the client assist to determine the
baseline measures related to their health.
In some instances, the nursing assessment will not incorporate the typical patient
history and interview if prioritization indicates that immediate action is urgent to preserve
the airway, breathing and circulation. This is also known as triage and is used in emergency
rooms and medical team disaster response situations. The patient history is documented
through a personal interview with the client and/or the client's family. If there is an urgent
need for a focused assessment, the most obvious or troubling complaint will be addressed
first. This is especially important in the case of extreme pain.
Physical examination

Assessing blood pressure

A nursing assessment includes a physical examination: the observation or measurement
of signs, which can be observed or measured, or symptoms such as nausea or vertigo, which
can be felt by the patient.
The techniques used may include inspection, palpation, auscultation and percussion in
addition to the "vital signs" of temperature, blood pressure, pulse and respiratory rate, and
further examination of the body systems such as
the cardiovascular or musculoskeletal systems.[9]
Focused assessment

Neurovascular assessment

The nurse conducts a neurovascular assessment to determine sensory and muscular

function of the arms and legs in addition to peripheral circulation. The focused
neurovascular assessment includes the objective observation of pulses, capillary refill, skin
color and temperature, and sensation. During the neurovascular assessment the measures
between extremities are compared. A neurovascular assessment is an evaluation of the
extremities along with sensory, circulation and motor function.
Mental status

During the assessment, interactions and functioning are evaluated and documented. Those
specific items assessed include:
 orientation, memory,
 mood, depression, anxiety, coherence, hallucinations, illusions, insight
 speech patterns (rate, clarity clanging)
 grooming, personal hygiene, appropriateness of clothing
 response to verbal and tactile stimuli, level of consciousness, and alertness
 posture, gait, appropriateness of movements
Pain

Pain is no longer being identified as the fifth vital sign due to the prevalence of opioid abuse
and overprescribing of narcotic pain relievers. However, assessment for pain is still very
important. Assessment of a patient's experience of pain is a crucial component in providing
effective pain management. Pain is not a simple sensation that can be easily assessed and
measured. Nurses should be aware of the many factors that can influence the patient's
overall experience and expression of pain, and these should be considered during the
assessment process. Systematic process of pain assessment, measurement, and re-
assessment (re-evaluation), enhances the healthcare teams' ability to achieve. Pain is
assessed for its provocative and palliative associations; quality, region/radiation, severity
(numerical scale or pictorial, Wong-Baker Faces scale); and time—of onset, duration,
frequency, and length of provocative and relief measures.
Integument

Performing an eye exam by military nurses

 hair: quantity, location, distribution, texture
 nails: shape and color, presence of clubbing
  lesions: type, location, arrangement, color of lesions, drainage, depth, width, length
 texture, moisture, color, elasticity, turgor
Head
 scalp, facial symmetry, sensation
 eyes
 acuity
 eyelids
 lacrimal glands
 conjunctiva
 visual fields
 peripheral vision
 sclera
 size, shape, symmetry, pupil reactions
 movement (cranial nerves)
 ears
 external structure
 inner ear
 eardrum
 hearing (frequencies of sound detected)
 dentation
Psychosocial assessment

Abdominal palpation of a boy

The main areas considered in a psychological examination are intellectual health and
emotional health. Assessment of cognitive function, checking for hallucinations and
delusions, measuring concentration levels, and inquiring into the client's hobbies and
interests constitute an intellectual health assessment. Emotional health is assessed by
observing and inquiring about how the client feels and what he does in response to these
feelings. The psychological examination may also include the client's perceptions (why they
think they are being assessed or have been referred, what they hope to gain from the
meeting). Religion and beliefs are also important areas to consider. The need for a physical
health assessment is always included in any psychological examination to rule out structural
damage or anomalies.
Safety

 environment
 ambulatory aids
Cultural assessment

The nursing cultural assessment will identify factors that may impede or facilitate the
implementation of a nursing diagnosis. Cultural factors have a major impact on the nursing
assessment. Some of the information obtained during the interview include:
 ethnic origin
 primary language
 second language
 the need for an interpreter
 the client's main support system(s)
 family living arrangements
 Who is the major decision maker in the family? What are the family members' roles
within the family
 Describe religious beliefs and practices
 Are there any religious requirements/restrictions that place limitations on the
client's care?
 Who in the family takes responsibility for health concerns?
 Describe any special health beliefs and practices:
 From whom does family usually seek medical assistance in time of need?
 Describe client's usual emotional/behavioral response to: Anxiety: Anger:
Loss/change/failure: Pain: Fear:
 Describe any topics that are particularly sensitive or that the client is unwilling to
discuss (because of cultural taboos):
  Describe any activities in which the client is unwilling to participate (because of
cultural customs or taboos):
 What are the client's personal feelings regarding touch?
 What are the client's personal feelings regarding eye contact?
 What is the client's personal orientation to time? (past, present, future)
 Describe any particular illnesses to which the client may be bioculturally susceptible
(e.g., hypertension and sickle cell anemia in *African Americans):
 Describe any nutritional deficiencies to which the client may be bioculturally
susceptible (e.g., lactose intolerance in Native and Asian Americans)
 Are there any foods the client requests or refuses because of cultural beliefs related
to this illness (e.g., "hot" and "cold" foods for Latino Americans and Asian Americans)
Assessment tools

Auscultation assessing lung sounds

A range of instruments and tools have been developed to assist nurses in their assessment
role. These include: the index of independence in activities of daily living,[18] the Barthel
index, the Crighton Royal behaviour rating scale,[20] the Clifton assessment procedures for
the elderly,the general health questionnaire,[22] and the geriatric mental health state
schedule.
Other assessment tools may focus on a specific aspect of the patient's care. For example,
the Waterlow score and the Braden scale deals with a patient's risk of developing a Pressure
ulcer (decubitus ulcer), the Glasgow Coma Scale measures the conscious state of a person,
and various pain scales exist to assess the "fifth vital sign".
The use of medical equipment is routinely employed to conduct a nursing assessment.
These include, the otoscope, thermometer, stethoscope, penlight, sphygmomanometer,
bladder scanner, speculum, and eye charts. Besides the interviewing process, the nursing
assessment utilizes certain techniques to collect information such as observation,
auscultation, palpation and percussion.

Nursing diagnosis
A nursing diagnosis may be part of the nursing process and is a clinical judgment about
individual, family, or community experiences/responses to actual or potential health
problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g.,
patient comfort or relief) compared to dependent interventions driven by physician's orders
(e.g., medication administration). Nursing diagnoses are developed based on data obtained
during the nursing assessment. A problem-based nursing diagnosis presents a problem
response present at time of assessment. Risk diagnoses represent vulnerabilities to
potential problems, and health promotion diagnoses identify areas which can be enhanced
to improve health. Whereas a medical diagnosis identifies a disorder, a nursing diagnosis
identifies the unique ways in which individuals respond to health or life processes or
crises. The nursing diagnostic process is unique among others. A nursing diagnosis integrates
patient involvement, when possible, throughout the process. NANDA International
(NANDA-I) is body of professionals that develops, researches and refines an official
taxonomy of nursing diagnosis.
All nurses must be familiar with the steps of the nursing process in order to gain the most
efficiency from their positions. In order to correctly diagnose, the nurse must make quick
and accurate inferences from patient data during assessment, based on knowledge of the
nursing discipline and concepts of concern to nurses.

NANDA International
NANDA International, Inc.,formerly known as the North American Nursing Diagnosis
Association, is the primary organization for defining, researching, revising, distributing and
integrating standardized nursing diagnoses worldwide. NANDA-I has worked in this area for
more than 45 years to ensure that diagnoses are developed through a peer-
reviewed process requiring standardised levels of evidence, definitions, defining
characteristics, related factors or risk factors that enable nurses to identify potential
diagnoses in the course of a nursing assessment. NANDA-I believes that it is critical that
nurses are required to utilise standardised languages that provide not just terms (diagnoses)
but the embedded knowledge from clinical practice and research that provides diagnostic
criteria (definitions, defining characteristics) and the related or etiologic factors upon which
nurses intervene. NANDA-I terms are developed and refined for actual (current) health
responses and for risk situations, as well as providing diagnoses to support health
promotion. Diagnoses are applicable to individuals, families, groups and communities. The
taxonomy is published in multiple countries and has been translated into 18 languages; it is
in use worldwide. As research in the field of nursing continues to grow, NANDA-I continually
develops and adds new diagnostic labels.
Nursing diagnoses are a critical part of ensuring that the knowledge and contribution of
nursing practice to patient outcomes are found within the electronic health record and can
be linked to nurse-sensitive patient outcomes.

Global
The ICNP (International Classification for Nursing Practice) published by the International
Council of Nurses has been accepted by the World Health Organization family of
classifications. ICNP is a nursing language which can be used by nurses to diagnose.

Structure
The NANDA-I system of nursing diagnosis provides for four categories and each has 3 parts:
diagnostic label or the human response, related factors or the cause of the response, and
defining characteristics found in the selected patient are the signs/symptoms present that
are supporting the diagnosis.
1. Problem-focused diagnosis
A clinical judgment about human experience/responses to health conditions/life processes
that exist in an individual, family, or community. An example of an actual nursing diagnosis
is: Sleep deprivation.
2. Risk diagnosis
Describes human responses to health conditions/life processes that may develop in a
vulnerable individual/family/community. It is supported by risk factors that contribute to
increased vulnerability. An example of a risk diagnosis is: Risk for shock.
3. Health promotion diagnosis
A clinical judgment about a person's, family's or community's motivation and desire to
increase wellbeing and actualise human health potential as expressed in the readiness to
enhance specific health behaviours, and can be used in any health state. An example of a
health promotion diagnosis is: Readiness for enhanced nutrition.
4. Syndrome diagnosis
A clinical judgment describing a specific cluster of nursing diagnoses that occur together,
and are best addressed together and through similar interventions. An example of a
syndrome diagnosis is: Relocation stress syndrome.

Process
The diagnostic process requires a nurse to use critical thinking. In addition to knowing the
nursing diagnoses and their definitions, the nurse becomes aware of defining characteristics
and behaviors of the diagnoses, related factors to the diagnoses, and the interventions
suited for treating the diagnoses.
1. Assessment
The first step of the nursing process is assessment. During this phase, the nurse gathers
information about a patient's psychological, physiological, sociological, and spiritual status.
This data can be collected in a variety of ways. Generally, nurses will conduct a patient
interview. Physical examinations, referencing a patient's health history, obtaining a patient's
family history, and general observation can also be used to gather assessment data. Patient
interaction is generally the heaviest during this evaluative stage.
2. Diagnosis
The diagnosing phase involves a nurse making an educated judgement about a potential or
actual health problem with a patient. Multiple diagnoses are sometimes made for a single
patient. These assessments not only include a description of the problem or illness (e.g.
sleep deprivation) but also whether or not a patient is at risk of developing further
problems. These diagnoses are also used to determine a patient's readiness for health
improvement and whether or not they may have developed a syndrome. The diagnoses
phase is a critical step as it is used to determine the course of treatment.
3. Planning
Once a patient and nurse agree of the diagnoses, a plan of action can be developed. If
multiple diagnoses need to be addressed, the head nurse will prioritise each assessment and
devote attention to severe symptoms and high risk patients. Each problem is assigned a
clear, measurable goal for the expected beneficial outcome. For this phase, nurses generally
refer to the evidence-based Nursing Outcome Classification, which is a set of standardised
terms and measurements for tracking patient wellness. The Nursing Interventions
Classification may also be used as a resource for planning.
4. Implementation
The implementing phase is where the nurse follows through on the decided plan of action.
This plan is specific to each patient and focuses on achievable outcomes. Actions involved in
a nursing care plan include monitoring the patient for signs of change or improvement,
directly caring for the patient or performing necessary medical tasks, educating and
instructing the patient about further health management, and referring or contacting the
patient for a follow-up. Implementation can take place over the course of hours, days,
weeks, or even months.
5. Evaluation
Once all nursing intervention actions have taken place, the nurse completes an evaluation to
determine if the goals for patient wellness have been met. The possible patient outcomes
are generally described under three terms: patient's condition improved, patient's condition
stabilised, and patient's condition deteriorated. In the event where the condition of the
patient has shown no improvement, or if the wellness goals were not met, the nursing
process begins again from the first step.
Examples

The following are nursing diagnoses arising from the nursing literature with varying degrees
of authentication by ICNP or NANDA-I standards.
 Anxiety
 Constipation
 Pain
 Decreased Activity Tolerance
 Impaired Gas Exchange
 Excessive Fluid Volume
 Caregiver Role Strain
 Ineffective Coping
 Readiness for Enhanced Health Maintenance
 Readiness for enhanced spiritual well-being

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