Nursing
The nursing process is a systematic, client-centered approach to nursing care introduced by Ida Jean Orlando in 1958. It consists of five sequential steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE). This approach emphasizes critical thinking, evidence-based practice, and nursing intuition.
Assessment: Collect data about the patient’s health status, including vital signs and patient reports. Professional nurses must perform this step and delegate data collection tasks as appropriate.
Diagnosis: Develop nursing diagnoses based on patient responses to health problems, rather than medical diagnoses which focus on pathological conditions. Nursing diagnoses include a three-part statement: the problem, the related factors or causes, and the defining characteristics (evidence).
Planning: Identify expected outcomes and create a plan of care. This plan should address the patient's needs and include specific interventions.
Implementation: Carry out the planned interventions. While some tasks can be delegated, the overall responsibility for implementation lies with the professional nurse.
Evaluation: Assess the outcomes of the interventions and adjust the care plan as necessary.
Critical Thinking is essential throughout the nursing process, guiding nurses to make informed decisions and adapt care based on patient responses. Delegation guidelines emphasize that while specific tasks can be assigned to others, core components of the nursing process (assessment, planning, evaluation, and nursing judgment) must be carried out by a professional nurse.
Nursing diagnosis differ from medical diagnoses by focusing on the patient's responses to health issues and identifying factors that affect these responses. They are dynamic and can change as the patient's condition evolves, unlike medical diagnoses, which typically remain constant.
Nursing Process and Components:
Assessment: Collect and analyze patient data to determine health needs.
Diagnosis: Develop nursing diagnoses based on patient responses, including the problem, related factors, and defining characteristics.
Planning: Establish goals and plan interventions to address patient needs.
Implementation: Execute the care plan and interventions.
Evaluation: Assess the effectiveness of interventions and adjust the care plan as needed.
Examples of Nursing Diagnoses:
Fall risk related to unsteady gait as evidenced by a history of falls.
Knowledge deficit related to new prescription medications as evidenced by incorrect teach-back.
Bathing self-care deficit related to fear of falling and obesity as evidenced by strong body and urine odors.
Critical Thinking in Nursing:
Definition: A combination of reasoned thinking, openness to alternatives, reflection, and a desire to seek truth.
Importance: Essential for navigating complex and unique patient scenarios, applying theoretical and practical knowledge, and ensuring holistic and evidence-based care.
Critical-Thinking Skills:
Gathering and evaluating information objectively.
Identifying knowledge gaps and prioritizing relevant data.
Making informed decisions and exploring potential solutions.
Implementation Purposes:
Achieve health outcomes.
Promote health, prevent illness, restore health, and facilitate coping.
Evaluation:
Determine if goals were met and if interventions were successful.
Adjust care plans based on the patient’s progress and outcomes.
Examples:
Knowledge deficit r/t (related to) new prescription medication aeb (as evidenced by) incorrect teach back
Bathing self care deficit related to fear of falling in the tub and obesity as evidenced by strong body odor