The Nursing Process Study Guide

🌟 The Nursing Process Study Guide

The nursing process is a systematic, patient-centered, goal-oriented method used to guide nurses in providing individualized care. It consists of five interrelated steps:

1. Assessment

🔍 “What’s going on with my patient?”

Purpose:

• To gather comprehensive data about the patient’s physical, psychological, sociocultural, spiritual, and lifestyle health.

Types of Data:

• Objective data: Observable & measurable signs
  ➤ Examples: Vital signs, lab results, physical assessment findings (e.g., skin rash, abnormal heart rate)

• Subjective data: What the patient says or feels (symptoms)
  ➤ Examples: "I feel dizzy," "My pain is a 7/10," or "I feel nauseous."

Tips:

• Use open-ended questions.

• Validate and double-check critical info.

• Prioritize accuracy and clarity (especially when charting!).

2. Diagnosis (Nursing Diagnosis)

🧠 “What’s the problem?”

Purpose:

• Analyze and interpret the assessment data.

• Identify patient problems that nurses can treat independently.

Process:

• Identify actual or potential health issues.

• Prioritize them using Maslow’s Hierarchy of Needs (e.g., airway > safety > love/belonging).

• Use NANDA-I approved nursing diagnoses.

Example:

• Actual Diagnosis: Impaired skin integrity related to immobility as evidenced by pressure ulcer on sacrum.

• Risk Diagnosis: Risk for falls related to impaired mobility.

3. Planning

📋 “What are we going to do about it?”

Purpose:

• Create a personalized nursing care plan with clearly defined goals.

Goals Should Be:

• SMART:
  ➤ Specific
  ➤ Measurable
  ➤ Achievable
  ➤ Relevant
  ➤ Time-bound

Tips:

• Prioritize care based on urgency and impact.

• Collaborate with patient and care team.

Example of a SMART Goal:

• "Patient will report pain level ≤ 3/10 within 1 hour of analgesic administration."

4. Implementation

🚑 “Let’s put the plan into action.”

Purpose:

• Carry out the nursing interventions outlined in the care plan.

Includes:

• Administering medications

• Providing treatments or procedures

• Educating the patient

• Coordinating care with other healthcare professionals

Tips:

• Always reassess before intervening.

• Document EVERYTHING immediately after completion.

5. Evaluation

📝 “Did it work?”

Purpose:

• Review the outcomes of interventions.

• Determine if patient goals were met.

Process:

• Assess the patient’s response.

• Modify or continue the care plan as needed.

Example:

• Goal met: Pain reduced to 2/10 → Continue current plan.

• Goal not met: Pain still 7/10 → Reassess meds, update plan.

📌 Additional Notes:

• The nursing process is cyclical, not linear. If goals aren’t met in Evaluation, reassess and go back to Step 1.

• Use critical thinking throughout all steps.

• Always involve the patient and respect their preferences and values.

• Legal & ethical documentation: Every step must be charted correctly—it protects both you and the patient.

🧠 Quick Mnemonic:

ADPIE =
Assessment
Diagnosis
Planning
Implementation
Evaluation

💡 Try this memory trick:
“A Delicious Pie Is Everything”