Nursing Process Lecture Notes

Introduction

• Instructor: Jim Hoffman
• Focus: Understanding what nurses do and how they do it, specifically through the nursing process.
• Importance: Guides nurses in practice; operationalizes standards of professional practice by ANA.

Nursing Process Overview

• Framework: Guides nurse-patient relationships and directs actions.
• Acronym: ADOPIE
  • A: Assessment
  • D: Diagnosis
  • O: Outcomes Identification
  • P: Planning
  • I: Implementation
  • E: Evaluation
• Continuous Cycle: Constant assessment and reassessment as patient conditions change.

Assessment

• Purpose: Data collection about patient's health status.
• Types of Data:
  • Subjective Data: Patient's perceptions (Primary from patient, Secondary from family/records).
  • Objective Data: Observable/measurable data (vital signs, lab tests).
• Data Collection Methods:
  • Interview
  • Physical Exam
  • Record Review
• Types of Assessments:
  • Primary Assessment: Initial check for emergencies (airway, breathing, circulation).
  • Admission Assessment: Comprehensive baseline data collection.
  • Ongoing Assessment: Routine check-ups in healthcare settings.
  • Focused Assessment: Detailed check on specific issues.
  • Time-lapsed Assessment: Periodic checks (e.g., every 90 days in extended care).

Diagnosis

• Process: Analyze assessment data to identify departures from normal.
• Types:
  • Nursing Diagnosis: Focuses on patient's responses to health issues.
  • Medical Diagnosis: Disease identification.
• Components of a Nursing Diagnosis:
  • Problem Statement: Title of diagnosis.
  • Etiology: Cause, marked by "related to".
  • Signs/Symptoms: Evidence, marked by "as manifested by".

Outcomes Identification

• Purpose: Determine desired results to address the nursing diagnosis.
• SMART Criteria:
  • Specific
  • Measurable
  • Attainable
  • Relevant
  • Time-bound
• Example: Clear lung sounds within 24 hours.

Planning

• Develop Interventions: Steps to achieve outcomes.
• Types of Interventions:
  • Independent: No orders needed (e.g., repositioning).
  • Dependent: Requires orders (e.g., medication).
  • Collaborative: Involves other healthcare team members.

Implementation

• Execution of Plan: Decide on priority interventions.
• Delegation: RNs can delegate tasks to LPNs, CNAs.
• Documentation: Essential for validation and continuity of care.

Evaluation

• Assessing Outcomes: Determine if goals are met.
• Feedback Loop: Continuous reassessment and adjustment of care plans.

Roles & Responsibilities

• RN: Responsible for entire nursing process.
• LPN: Supports RN with specific tasks within scope of practice.
• CNA/STNA: Executes delegated tasks.

Conclusion and Next Steps

• Upcoming Focus: Further explore assessment, especially physical assessment.
• Guidance: Use study guides and assigned readings to deepen understanding.