Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care
plan/care map: ADPIE. From our beloved Daytonite....RIP
- Assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
- Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
- Planning (write measurable goals/outcomes and nursing interventions)
- Implementation (initiate the care plan)
- Evaluation (determine if goals/outcomes have been met)
plan/care map is nothing more than the written documentation of the nursing process
you use to solve one or more of a patients nursing problems. The nursing process itself is
a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. Tune of the main goals every nursing school wants its RNs to learn by graduation is how to use the nursing process to solve patient problems.
Care plan reality: T
he foundation of any care
plan is the signs, symptoms or responses
that patient is having to what is happening to them. What is happening to them could be a medical disease, a physical condition, a failure to be able to perform ADLs(activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on.......the more the better. You will have to be a detective and always be on the alert and lookout for clues.......at all times. That is within the spirit of step #1 of this whole nursing process.
Assessment is an important skill. It will take you a long time to become proficient in assessing patients. assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. history can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers. part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.
A nursing diagnosis standing by itself means nothing.
The meat of the care
plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient. In order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.
Care plan reality:
Is actually a shorthand label for the patient problem
. The patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition). [thanks daytonite]
What I would suggest you do is to work the nursing process from step
#1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms.
#2. Don't forget to include an assessment of their ability to perform adls (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.
#3. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. Did you miss any of the signs and symptoms in the patient? If so, now is the time to add them to your list.
This is all part of preparing to move onto the next step of the process which is
#4. Determining your patients problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.
#5. How are all your interventions changing/helping this patient.
You, I and just about everyone we know have been using a form of the scientific process, or nursing process, to solve problems that come up in our daily lives since we were little kids.
For example: As a contributor to AN....Daytonite said best.
You are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. You pull over to the side of the road. "What's wrong?" You're thinking. You look over the dashboard and none of the warning lights are blinking. You decide to get out of the car and take a look at the outside of the vehicle. You start walking around it. Then, you see it..............a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated.
What you have just done is.......
Step #1 of the nursing process--performed an assessment. You determine that you have a flat tire. You have just done.....
Step #2 of the nursing process--made a diagnosis. The little squirrel starts running like crazy in the wheel up in your brain. "What do i do?" You are thinking. You could call AAA. No, you can save the money and do it yourself. You can replace the tire by changing out the flat one with the spare in the trunk. .......Good thing you took that class in how to do simple maintenance and repairs on a car!
You have just done.....
Step #3 of the nursing process--planning (developed a goal and intervention). You get the jack and spare tire out of the trunk, roll up your sleeves and get to work. You have just done.....
Step #4 of the nursing process--implementation of the plan. After the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. You begin slowly to test the feel as you drive....... Good....... Everything seems fine. The spare tire seems to be ok and off you go and on your way. You have just done
Step #5 of the nursing process--evaluation (determined if your goal was met).
Does this make more sense? Can you relate to that? That's about as simple as the nursing process can be simplified to... BUT........ you have the follow those 5 steps in that sequence or you will get lost in the woods and lose your focus of what you are trying to accomplish.
critical thinking involves knowing:
- the proper sequence of steps in the nursing process
- the normal anatomy and physiology of the human body
- how the normal anatomy and physiology are changed by the medical and disease process that are going on
- the normal medical treatment that the doctor(s) are likely to order to treat the medical and disease process going on
- the nursing interventions that you have learned for the things that support the medical and disease process that is going on
- making the connection (this is the critical thinking part) between the disease, the treatment and the nursing interventions and where on the sequence of the nursing process you are
So I am sure this is now clear as mud.......questions?