Nursing

Nursing Process

A systematic, client-centered approach to nursing care consisting of five sequential steps:Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE).

Assessment

The step in the nursing process where data about the patient’s health status is collected, including vital signs and patient reports.

Diagnosis

The development of nursing diagnoses based on patient responses to health problems, focusing on the problem, related factors, and defining characteristics.

Planning

The process of identifying expected outcomes and creating a plan of care that addresses the patient's needs and includes specific interventions.

Implementation

The execution of the planned interventions, with overall responsibility resting on the professional nurse.

Evaluation

The assessment of the outcomes of interventions and the adjustment of the care plan as necessary.

Critical Thinking

A combination of reasoned thinking, openness to alternatives, reflection, and a desire to seek truth, essential throughout the nursing process.

Delegation Guidelines

Guidelines emphasizing that while specific tasks can be delegated, core components of the nursing process must be performed by a professional nurse.

Nursing Diagnosis

Focuses on the patient's responses to health issues and identifies factors affecting these responses, differing from medical diagnoses.

Dynamic Nature of Nursing Diagnoses

Nursing diagnoses can change as the patient's condition evolves, unlike medical diagnoses which typically remain constant.

Examples of Nursing Diagnoses

Specific statements that illustrate nursing diagnoses, such as fall risk related to unsteady gait or knowledge deficit related to new prescription medications.

Critical-Thinking Skills

Skills that include gathering and evaluating information objectively, identifying knowledge gaps, and making informed decisions.

Implementation Purposes

The goals of implementation, which include achieving health outcomes, promoting health, preventing illness, restoring health, and facilitating coping.

Evaluation Purpose

To determine if goals were met and if interventions were successful, adjusting care plans based on patient progress and outcomes.