A better understanding of the NURSING PROCESS

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Specializes in future speciality interest: Nurse Midwif.

Can anyone help me understand the Nursing Process.

So far I am using AD-PIE to remember the order.

Plus, how to figure out the phrases need to complete a Nursing Diagnosis.

Thanks

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Specializes in med/surg, telemetry, IV therapy, mgmt.

the nursing process is quite simply a problem solving process. it was extrapolated from the scientific process. however, you have been using a more common methodology similar to the nursing process to work out problems in your own personal life for years and you learned it through trial and error. let me give you an analogy that you can recognize and explain how it is similar to the nursing process:

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).

here is a website with another analogy to real life:

what the nursing process does is take this problem solving process and break it into 5 defined steps giving you specific tasks you need to do in each step. if you were a chemist working on some research, you would have a similar type of problem solving process to follow, but it wouldn't be called the nursing process. however, it would certainly involve reviewing the data that is known, determining what the problems are, planning the next experiment, initiating it and then evaluating the results. this is what makes our profession scientifically based--this problem solving process is rational and based on principles of critical thinking.

now, adpie is the mnemonic, a memory tool, for the 5 steps of the nursing process. the little scenario i posted above is another type of memory tool, a story. you can earn about other memory tools here: http://www.psywww.com/mtsite/memory.html. but, you need you learn the nursing process one way or another because you are going to be using it from now until the day you retire from nursing. it is so useful. as a student it will help you organize and get through the writing of care plans. it also works in just solving problems that come up in clinicals and on the job. something that i realized several years into my working life is that looking for and collecting data on a patient is a constant activity. one little piece of information can totally change the way we are treating a patient's nursing problem. assessment is the first, and most important, step of the nursing process.

here are the steps of the nursing process and what goes on in them:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. 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)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

and, if you want to read more about the nursing process, here are websites about it:

the phrases, or language, needed to complete nursing diagnostic statements are actually contained in the nanda taxonomy and you can use them until you develop a better understanding of the individual diagnoses and feel more comfortable composing your own statements to accompany the diagnostic labels (the shortened versions of the diagnostic problems). there are a number of ways to acquire this information.

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Specializes in Trauma/Burn ICU, Neuro ICU.

Daytonite,

I love you!

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First, I want to thank u I was so confuse with nursing process but the example u gave it help me so much....

Thank you!!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

now, this is how you expand on it and use it to create a care plan:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

[*]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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

[*]planning (write measurable goals/outcomes and nursing interventions)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]how to write goal statements: https://allnurses.com/forums/2509305-post158.html

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
      • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

      [*]care/perform/provide/assist (performing actual patient care)

      [*]teach/educate/instruct/supervise (educating patient or caregiver)

      [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

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