Notes on the Nursing Process

Overview

• The nursing process is a systematic method used by nurses to provide personalized care.
• It involves clinical reasoning and critical thinking.
• Developed in the 1950s by Lydia Hall.
• Traditionally involves cooperation with the client.
• Protects client rights and confidentiality.
• Madeline Leninger is a notable contributor to the field.

Five Steps of the Nursing Process (ADPIE)

1. Assessment

   • Initial and continuous step.
   • Collect comprehensive client data: subjective (client-reported) and objective (measurable) data.
   • Use critical thinking to identify relevant data and client strengths.
   • Utilize various forms and tools to ensure thoroughness.
   • Sources: client, medical records, diagnostic tests, health team, significant others.
   • Document findings, respect confidentiality, and use information appropriately.

2. Nursing Diagnosis

   • Approved by NANDA International.
   • Analyze assessment data to identify the client's needs and problems.
   • Formulating diagnosis involves critical thinking and comparing with NANDA definitions.
   • Document using institutional forms.

3. Planning

   • Develop a plan based on the diagnosis.
   • Set mutual, achievable outcomes using the SMART criteria: Specific, Measurable, Attainable, Realistic, Time-bound.
   • Select interventions aligned with client goals.
   • Utilize standardized nursing language and document meticulously.

4. Implementation

   • Act on the plan by delivering nursing care.
   • Evaluate client responses and adjust interventions as needed.
   • Document care activities and client responses.

5. Evaluation

   • Continuous process of assessing the effectiveness of the care delivered.
   • Critical questions include the success of outcomes and the need for reassessment.
   • Modify care plans based on evaluation.

Critical Thinking in Nursing

• Essential throughout the process to validate information and make informed decisions.
• Involves analyzing data, understanding its significance, and deciding on interventions.

Documentation and Confidentiality

• Vital for communication among the health team and maintaining client privacy.
• Follow institutional protocols for documentation.
• Client information must be protected, especially with technology.

References

• The lecture content references the Ackley and Ladwig Nursing Diagnosis Handbook and the Fundamentals of Nursing textbook chapters 16-20.

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Note: If there are questions regarding the content, contact the professor for clarification.