Nursing Process Steps (CRITICAL THINKING)

Summary

In this video, Christina Rafano breaks down the nursing process step-by-step, making it easier for nursing students to understand and apply in clinical settings. She explains each phase of the process—Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE), emphasizing the importance of critical thinking and the patient’s response. Christina also introduces a small variation in the process (ADOPIE) used by some nursing programs, where Outcome Identification precedes Planning. Viewers will also receive a helpful cheat sheet to guide them through the nursing process and improve their clinical and exam performance.

Takeaways

• 😀 The nursing process is a step-by-step system for nurses to follow in patient care, designed to ensure systematic and thorough assessment and care.
• 😀 The mnemonic ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation) helps nurses remember the steps in the nursing process.
• 😀 Assessment is the most important step of the nursing process, involving both data collection (vital signs, history, head-to-toe assessment) and critical thinking to evaluate the patient's condition.
• 😀 Critical thinking during assessment allows nurses to anticipate potential issues and adjust care based on the patient's responses and situation.
• 😀 Nursing diagnosis differs from medical diagnosis by focusing on the patient's response to their condition rather than the condition itself (e.g., 'anxiety' rather than 'asthma').
• 😀 Nursing diagnoses are standardized by NANDA-I (North American Nursing Diagnosis Association), which helps ensure consistency across nursing practices.
• 😀 Some nursing programs include an 'O' in ADPIE, making it ADOPIE, which stands for Outcome Identification, a goal-setting step to define the desired outcomes for patient care.
• 😀 Planning involves creating interventions that help the patient achieve their goals, such as collaborating with other healthcare professionals and educating the patient on specific techniques.
• 😀 Implementation is the action phase, where nurses carry out the planned interventions to help the patient meet their goals.
• 😀 Evaluation involves reassessing the patient to determine if they have met their goals and deciding if further changes or new goals are necessary to improve their care.
• 😀 A free cheat sheet is available to help students succeed with the nursing process and nursing assessments, offering guidance and tools for effective learning and application.

Q & A

What is the nursing process and why is it important?

The nursing process is a step-by-step system used by nurses to assess, diagnose, plan, implement, and evaluate patient care. It is crucial because it ensures a structured and thorough approach to patient care, improving outcomes and helping nurses provide the best care possible.

What is the mnemonic used to remember the steps of the nursing process?

The mnemonic used is ADPIE, which stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation. Some programs also use ADOPIE, where 'O' stands for Outcome Identification.

What is the significance of the 'A' in ADPIE, or the assessment step?

The assessment step is the most important in the nursing process. It involves gathering data through vital signs, patient history, and a head-to-toe assessment. Critical thinking is essential to identify underlying problems and assess further as needed.

What are the two main components of the nursing assessment?

The two main components are collecting data (such as vital signs, patient history, and physical assessment) and critical thinking, where the nurse continuously evaluates and interprets the patient's condition.

What is the difference between a medical diagnosis and a nursing diagnosis?

A medical diagnosis refers to a specific disease or condition (e.g., asthma or stroke), while a nursing diagnosis focuses on the patient's response to their condition (e.g., anxiety due to asthma or impaired mobility after a stroke).

What is the purpose of Outcome Identification (O) in some nursing programs?

Outcome Identification involves setting clear goals for the patient, defining what success looks like for the patient’s recovery, and helping to track progress toward these goals. It’s included as part of ADOPIE in some nursing programs.

How is planning in the nursing process carried out?

In the planning step, the nurse develops a game plan that outlines interventions to help the patient achieve their goals. These interventions may involve collaborating with other healthcare professionals, such as speech therapists, or educating the patient.

What happens during the implementation step of the nursing process?

During the implementation step, the nurse carries out the planned interventions, such as providing education, performing treatments, or setting up additional services, to help the patient meet their goals.

How does the evaluation step contribute to the nursing process?

The evaluation step assesses the progress of the patient toward their goals. It involves determining if the patient has met their goals and making any necessary adjustments to the plan to better support the patient’s recovery.

What is a critical tip for nurses when performing assessments?

A critical tip is to always assess the patient, not just rely on monitors. For example, even if a monitor shows abnormal readings, it’s important to consider how the patient is physically responding before making decisions like calling a code.