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.