Nursing Process Overview

Introduction

• Presented by Christina Rafano from nursingschoolofsuccess.com.
• Aimed at helping nursing students understand and master the nursing process.
• Offers a free cheat sheet and tips for succeeding in nursing school.

Common Confusion in Nursing Process

• Many students feel lost about what to do and when in the nursing process.
• The lecture provides a step-by-step guide to navigate the process.

What is the Nursing Process?

• A systematic, step-by-step guide that nurses follow with patients.
• Mnemonic: ADPIE
  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

Step 1: Assessment (A)

• Most crucial step in nursing.
• Comprises two components:
  1. Data Collection:
     • Vital signs, patient history, lifestyle questions, head-to-toe or focused assessment.
  2. Critical Thinking:
     • Analyze data to determine underlying issues, noticing changes in the patient’s condition.
• Bonus Tip: Evaluate the patient directly, not just rely on monitors.

Step 2: Diagnosis (D)

• Not a medical diagnosis but revolves around the patient’s response.
• Example: Instead of diagnosing "Asthma," a nursing diagnosis might be "anxiety" due to asthma.
• Standardized by NANDA-I (North American Nursing Diagnosis Association International).

Step 3: (Optional) Outcome Identification (O)

• Some schools include "Outcome Identification," making it ADOPIE.
• Involves setting goals for the patient.
• Example Goal: "The patient will show no signs of aspiration after meals."

Step 4: Planning (P)

• Develop a game plan or interventions to achieve the patient’s goals.
• Example Interventions:
  • Collaborate with speech pathology for swallowing techniques.
  • Educate and encourage the patient on these techniques.

Step 5: Implementation (I)

• Execute the planned interventions.
• Continue to encourage, educate, and support the patient.

Step 6: Evaluation (E)

• Assess if goals have been met and determine the need for changes.
• Continuous evaluation to support patient progress.

Conclusion

• Steps summarized as ADPIE (or ADOPIE when including outcome identification).
• Encouragement to download the free cheat sheet and subscribe for more tips.

Additional Information

• Importance of critical thinking and patient-centered care.
• Be proactive in reassessing and adjusting plans as necessary.
• Encouragement to become the best nurse possible.