Unit 3A The Nursing Process

Problem Solving Process

A systematic approach to identifying and resolving issues.

Identify the problem

The first step in problem-solving, focusing on recognizing the issue at hand.

Look for causes

Investigating the underlying reasons for the identified problem.

Identify possible methods to solve (Plan)

Generating potential solutions to address the problem.

Advantages / disadvantages

Evaluating the pros and cons of each potential solution.

Select Best Solution

Choosing the most appropriate solution from the options considered.

Carry out the plan (implement)

Executing the chosen solution.

Evaluate

Assessing the effectiveness of the implemented solution and making revisions as necessary.

ADPIE

An acronym representing the steps of the nursing process: Assessment, Diagnosing, Planning, Intervention, Evaluation.

Nursing Judgment

The ability to make informed decisions based on clinical knowledge as a nurse and patient data.

Critical Thinking

The process of analyzing and evaluating information to make reasoned judgments.

Clinical Reasoning

The cognitive process that guides nurses in making clinical decisions.

Integration of best evidence into practice

Utilizing the most current research and data to inform patient care.

Investigate deeper

The practice of not taking data at face value and seeking a deeper understanding.

Nursing Process

A methodical approach to patient care that emphasizes problem-solving and critical thinking.

Collecting data

The assessment phase of the nursing process, involving gathering relevant information.

Diagnosing

The identification of patient problems based on collected assessment data.

Planning

The phase where goals are set and interventions are determined to achieve desired outcomes.

Implementing

The execution of planned interventions to improve patient outcomes.

Evaluating effectiveness

The process of determining whether the interventions achieved the desired goals.

Characteristics of Nursing Process

Core elements include being patient-centered, collaborative, structured yet flexible, and continuous.

Cyclical and interrelated steps

The nursing process involves ongoing evaluation and reassessment therefore making it a cyclical process

Actual or potential diagnosis

Diagnoses can be based on current issues (actual) or risks for future problems (potential)

Subjective data

Information reported by the patient, such as feelings.

Objective data

Observable and measurable information, such as vital signs.

Cues

Directly observed facts that provide evidence about a patient's condition.

Inferences

Conclusions drawn from data that may not be directly observed.

Three Steps of the nursing process

Observing, Interviewing, Assessing.

Primary source

The patient, who provides firsthand information about their condition.

Secondary sources

Documents and records that provide additional information about the patient.

Analyzing data

The process of examining collected information to identify patterns and issues.

Comparing to standard

Evaluating patient data against established norms or benchmarks.

Nursing Diagnoses

Labels assigned to patient problems based on assessment data.

Gordon’s Functional Health Patterns

A framework used to organize nursing diagnoses based on various health aspects.

Evidence-based nursing interventions

Actions taken based on the best available research and clinical evidence.

SMART goals

Specific, Measurable, Achievable, Realistic, and Time-bound objectives for patient care.

Independent interventions

Nursing actions that do not require a physician's order.

Dependent interventions

Actions that require a physician's order, such as medication administration.

Collaborative interventions

Working with other healthcare professionals to provide comprehensive patient care.

Implementation

The phase of carrying out nursing interventions and documenting the process.

Evaluating patient response

Assessing whether the goals of care were met and determining necessary modifications.

Documenting/Reporting

The essential practice of recording and communicating patient care findings accurately and clearly.