Nursing Process: Fundamentals of Nursing

Introduction

• The nursing process is a cornerstone in nursing, facilitating individualized care.
• Originated in the 1950s by Lydia Hall.
• Integrates clinical reasoning and critical thinking.
• Cooperation with the client is ideal; ensure confidentiality and rights are respected.
• Use "ADPIE" acronym for steps:
  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

Step 1: Assessment

• Continuous process; begins with initial assessment and continues as needed.
• Gather information from multiple sources:
  • Client (primary source)
  • Medical records
  • Diagnostic tests
  • Health team
  • Significant others (as appropriate)
• Use open-ended questions to gather subjective data.
• Perform physical assessments to gather objective data.
• Critical thinking is crucial to analyze data and identify client problems and strengths.
• Documentation is important for communication and confidentiality must be preserved.

Step 2: Nursing Diagnosis

• Formulate diagnosis using NANDA International list.
• Use critical thinking to validate diagnosis.
• Compare client data with NANDA definitions.
• Document selected nursing diagnosis using institutional forms or systems.

Step 3: Planning

• Develop a plan based on diagnosis and data.
• Set mutual and measurable outcomes with the client.
• Use SMART criteria:
  • Specific
  • Measurable
  • Attainable
  • Realistic
  • Time-bound
• Select appropriate interventions from standardized nursing language.
• Document all planning in accordance with institutional guidelines.

Step 4: Implementation

• Execute the planned interventions.
• Consider critical questions:
  • How well did the client tolerate interventions?
  • Was timing suitable?
  • Were the appropriate personnel involved?
• Documentation should reflect the care given.

Step 5: Evaluation

• Continually assess effectiveness of interventions.
• Ask critical questions:
  • Were outcomes met satisfactorily?
  • Is further assessment needed?
  • Are outcomes realistic and achievable?
• Make necessary revisions to the plan of care.

Conclusion

• The nursing process is dynamic, requiring ongoing assessment and adjustments.
• Nurses must be proactive and adapt to client needs using evidence-based practice.
• Continuous documentation is key for effective communication and safe client care.

References

• Refer to Ackley & Ladwig's Nursing Diagnosis Handbook and other institutional resources for detailed guidance.

Tip: Always follow your institution's protocols and guidelines to ensure standardized care delivery and documentation.