Notes on Nursing Process Lecture

Introduction

• Presenter: Christina Rafano from nursingschoolofsuccess.com
• Purpose: Walk through the nursing process step by step
• Offer: Free cheat sheet for nursing assessments and exams
• Encouragement: Subscribe for more tips and resources

Common Student Confusion

• Many students feel lost regarding the nursing process
• Aim: To clarify the steps of the nursing process for better understanding

Overview of the Nursing Process

• Definition: A step-by-step system for what nurses do
• Mnemonic: ADPIE
  • A = Assessment
  • D = Diagnosis
  • P = Planning
  • I = Implementation
  • E = Evaluation
• Note: Some programs use ADOPIE (adding O = Outcome Identification)

Step 1: Assessment (A in ADPIE)

• Importance: Most crucial step for nurses
• Components:
  1. Collecting Data:
     • Vital signs, patient history, head-to-toe assessment
     • Questions on lifestyle, spirituality, psychological health, relationships, stressors
  2. Critical Thinking:
     • Observe and interpret patient responses and behaviors
     • Example: Assessing a cardiac patient based on their activity, not just monitor readings
• Bonus Tip: Always assess the patient, not just the monitors.

Step 2: Diagnosis (D in ADPIE)

• Concept: Nursing diagnosis vs. medical diagnosis
  • Nursing Diagnosis: Patient's response to their condition
  • Example:
    • Medical Diagnosis: Asthma
    • Nursing Diagnosis: Anxiety due to asthma
• Standardization: Nursing diagnoses are standardized by NANDA-I
  • Nursing textbooks contain lists of these standardized diagnoses

Step 3: Outcome Identification (O in ADOPIE)

• Definition: Identifying what successful goal achievement looks like
• Example:
  • Nursing Diagnosis: Impaired swallowing
  • Goal: "The patient will demonstrate techniques to prevent aspiration during meals"

Step 4: Planning (P in ADPIE)

• Definition: Developing a plan to meet patient goals
• Example:
  • Interventions for improving swallowing techniques, collaborating with speech language pathology

Step 5: Implementation (I in ADPIE)

• Definition: Carrying out the planned interventions
• Example:
  • Setting up evaluations, encouraging patient participation, educating patients on techniques

Step 6: Evaluation (E in ADPIE)

• Definition: Assessing patient progress towards goals
• Purpose: Determine if goals are met and if changes are needed in the care plan

Conclusion

• Overview of the nursing process summarized:
  • A: Assessment
  • D: Diagnosis
  • O: Outcome Identification (if applicable)
  • P: Planning
  • I: Implementation
  • E: Evaluation
• Call to Action: Grab the free cheat sheet linked in the video description and support the channel by liking, sharing, and subscribing.