Nursing Process

Nursing Process

Nursing Process Overview

  • The nursing process serves as an organizing framework for professional nursing practice.
  • It mirrors the steps involved in scientific reasoning and problem-solving.
  • It forms the bedrock for cultivating clinical decision-making skills.
  • It functions as a tool for devising care plans for patients, families, communities, or populations.
  • The nursing process is introduced early in students' professional identity formation as part of professional vocabulary and alongside the development of professional nursing practice.
  • It is important to explore the distinction and relationship between the nursing process and clinical judgement.

ADPIE: The Five Steps

  • The nursing process is commonly represented by the acronym ADPIE, which stands for:
    • Assessment
    • Diagnosis
    • Planning
    • Implementation
    • Evaluation

Assessment and Nursing Diagnosis

Assessment

  • Assessment is a systematic and dynamic process where nurses collect and analyze patient data, marking the initial step in delivering nursing care.
  • Assessment encompasses not only physiological data but also psychological, sociocultural, spiritual, economic, and lifestyle factors.

Diagnosis

  • Nursing diagnosis represents the nurse's clinical judgment concerning the patient's response to existing or potential health conditions or needs.
  • It is the foundation upon which the nursing care plan is built.
  • Historical Context: The North American Nursing Diagnosis Association (NANDA) was established in the 1970s to:
    • Develop a standardized language.
    • Create standardized nursing diagnoses based on a nurse's interpretation of assessment data.

Planning, Implementation, and Evaluation

Outcomes / Planning

  • Drawing from the assessment and diagnosis, nurses define measurable and attainable goals for the patient, covering both short-term and long-term objectives.
  • Assessment data, diagnosis, and goals are documented in the patient’s care plan, ensuring accessibility for nurses and other healthcare professionals involved in the patient’s care.

Implementation

  • Nursing care is carried out as per the developed care plan.
  • The overarching goal is to ensure continuity of care across various settings, including:
    • Hospitals
    • Outpatient primary care clinics
    • Hospice facilities
    • Schools
    • Skilled nursing facilities
    • Homes
  • All care provided is documented in the patient's record.

Evaluation

  • The patient’s condition and the effectiveness of the nursing care delivered are continuously evaluated.
  • The care plan is revised as necessary, based on the evaluation outcomes.

Nursing Diagnosis: Components

  • A nursing diagnosis typically consists of two or three parts:
    • Diagnosis / Related To (RT)
    • Defining Characteristics / Evidence or Symptoms (AEB or S)
  • Diagnosis: Describes the human response to health conditions or life processes.
  • Related To: Identifies the causes, contributing factors, or influences on the problem.
  • Defining Characteristics or As Evidenced By: Represents observable signs and symptoms.
  • Examples can be found in resources like the Ackley Nursing Diagnosis Handbook.
  • These diagnoses have implications for interprofessional collaborative practice.

Evaluation: Goal Articulation

  • Nurses define both short-term and long-term goals.
  • Goals should be SMART:
    • Specific
    • Measurable
    • Attainable
    • Realistic
    • Time-bound
  • This approach ensures a patient-centered focus in nursing practice and care.

Patient-Centered Goals

  • Diagnosis-specific treatment outcomes
  • Reduction or maintenance of symptoms
  • Reduction or maintenance of pain/suffering
  • Knowledge and understanding of medical conditions or symptoms
  • Maintenance of/improvement in physical or cognitive function
  • Improvement in well-being and/or coping skills
  • Maintenance of/increase in independence
  • Maintenance of/improvement in quality of life
  • Extension of life expectancy
  • Renewal of hobbies and activities
  • Ability to attend a specific function or event
  • Inclusive of family and caregivers

Implications for Nursing Practice

  • The nursing process is not linear, despite often being represented as a consecutive series of steps.
  • Assessment and evaluation should occur continuously, contributing to a dynamic process grounded in clinical reasoning and judgment.
  • This approach is vital for:
    • Effective problem-solving
    • Error prevention and minimizing patient harm
    • Developing clinical judgment
    • Integrated care planning
    • Interprofessional practice

Vignette: Applying the Nursing Process

  • Patient: Suzanne, a 74-year-old woman hospitalized with pneumonia.
    • History: Weighed 152 pounds 10 months ago; current weight is 137 pounds.
    • Complaints: Reports feeling tired, weak, and with hardly any energy.
    • Vitals: HR 62, BP 113/65, RR 18, T = 101 degrees F.
    • Other: Experiences dizziness when assisted from wheelchair to bed; uses a cane at home due to a stroke three years prior; lives alone; daughter visits several times each week.
  • Task: Apply the nursing process to plan care for this patient in small groups.