The following slides are from the Ackley and Ladwig Nursing Diagnosis Handbook. Chapters 16 through 20 in the Fundamentals of Nursing textbook look further into the concepts described here. The Nursing Process, Five Steps to Individualized, Personalized Nursing Care. The nursing process has been used in nursing for a very long time. It is how nurses think and how they identify client problems.
determine outcomes, and prioritize nursing care for clients. What Nurses Do was officially labeled as the nursing process in the 1950s by Lydia Hall. The nursing process uses clinical reasoning and critical thinking in all the steps. The process is ideally done in cooperation with the client.
When this is not possible, a designated person must be identified. At all times, the client's rights and confidentiality are respected. Madeline Leninger, a respected nursing leader, is someone that you learned about in week one of Nursing 310. Caring has always been within the domain of nursing. The nursing process is a five-step process based on the scientific process.
The acronym ADPIE is a useful way to remember the steps of the nursing process. A equals assessment. D equals nursing diagnosis.
P equals plan. I equals implementation. and E equals evaluation. Step one, assessment.
The first step of the nursing process is assessment. It is also a part of the process that is continuous. The client is assessed initially and then continually as care is administered and as the client's condition changes or progresses.
Most agencies and schools have an assessment form that is used. Be careful to fill in as much data as possible and validate the accuracy of subjective data with your client. Assessment is the initial step of the nursing process.
During this step, information about the client is gathered. The information should encompass the whole person and help to identify areas that the client deems problematic. The client's strengths also need to be identified. This is important because strengths can be supportive in changing problems and enhancing quality of life for the client.
As the nurse assesses the client, critical thinking is used to determine appropriate and relevant data. There are many assessment forms available to ensure that appropriate information is gathered and that appropriate information is not missed. There are several tools written by nurse leaders. They are all designed to assist the client to attain the highest level of health.
Assessment information is obtained from many sources. The first and most important source is the client. A thorough history and physical should be done by the nurse.
Medical records are reviewed. Diagnostic tests that have been ordered by the physician or nurse practitioner are also reviewed. The entire health team is essential to obtain a complete assessment. Significant others may be included if appropriate.
Asking open-ended questions encourages the client to talk and to share pertinent information. Here are some examples that you could use to start the health history. The information that the client tells you is considered to be subjective data. After the history is obtained, it is important to perform a physical assessment. All of this information will be documented on the assessment form and would be the objective data.
Using clinical reasoning allows the nurse to capture the client trends as they emerge in context. While clinical reasoning uses different words, such as cues, it includes all of the same information as ADPAI and the nursing process. Clinical judgment includes the prioritization of decisions based on the assessment data that guides nursing care.
The nurse employs complex cognitive processes that require gathering and analyzing client data, understanding the significance of the information to determine interventions, weighing alternative actions, and adjusting the plan of care as deemed necessary based on the nurse's clinical judgment. Using critical thinking to validate the information is an important part of this step. It is important to elicit responses from the client on how the findings are affecting the client.
This is where the nurse puts it all together to develop an appropriate plan of care. It is a systematic way to organize the data found in the assessment. Make a list of all the information in the assessment that you highlighted or underlined as client problems.
Look carefully at the list and then group problems that are similar together. Ask, what diagnosis are these pointing to? Prioritize the problems.
Maslow's hierarchy puts physiological possible life-threatening issues first. This is an objective way of looking at the data. When the data are identified and prioritized, it must be written and reported.
When doing the assessment, if the nurse encounters any of the situations shown on the slide, it should be reported immediately so that appropriate action can be taken. Documentation is a very important part of the nursing process. It enables all members of the health team to be knowledgeable about what is going on with the client.
Client confidentiality must always be protected. Only share information with healthcare professionals involved with the client's care. Information may also be used for classroom assignments, but the client's name must not be used. Information cannot be shared outside the classroom or clinical setting. Many places have the practice of using clients initials.
Follow the protocol that is used by your institution. Technology has created new dilemmas for maintaining confidentiality. The client's confidentiality extends to the use of technology. Client information cannot be shared via technology without specific and documented consent. Step 2. Nursing Diagnosis.
This is the second step of the nursing process. This information was approved at the 9th Nursing Diagnosis Conference in 1990. and has been applied in practice since that time. The NANDA International approved list is available in the Ackley-Ladwig text on the back cover.
In section 2 of the Ackley-Ladwig text, there are possible nursing diagnoses listed for medical, psychiatric conditions, client symptoms, problems, clinical states, surgeries, and diagnostic testing. Check the assessment and look for one of these mentioned headings. Check the nursing diagnoses listed under the heading.
Is it appropriate for this client? Critical thinking is applied to the assessment information to formulate a nursing diagnosis. Is the information in the assessment? Would a nursing intervention support a change?
Compare the data with the NANDA International definition. Do the signs and symptoms of the client match the defining characteristics supplied by NANDA International? The first part of the nursing diagnosis statement is the nursing diagnosis taken from the NANDA International List. The etiology is listed in the Ackley-Ladwig text or can be found at the Evolve Care Plan Constructor on the page or site that contains the nursing diagnosis label.
The defining characteristics will be at the same page or site. Ask again. These questions validate that the correct nursing diagnosis has been selected.
After you have selected the nursing diagnosis and are satisfied that the statement meets all the appropriate criteria, it needs to be documented. Use the form or system that your institution has supplied. Step 3. Planning. The third step of the nursing process is the planning step.
This is a very important step of the nursing process. You have all your data and you have made a diagnosis. Now what? A plan is needed.
Mutual outcomes need to be determined and a way to accomplish and measure the outcomes must be developed. This is where the critical thinking process continues. Writing, selecting outcomes, and writing and selecting interventions is part of the planning phase. Select those outcomes and actions that are appropriate for the client.
Necessary questions to answer include those listed on the slide, such as what does the client hope to accomplish and how will the outcomes be measured? Outcomes must meet the SMART requirements, specific, measurable, attainable, realistic, and have a time frame. Outcomes may be selected from standardized nursing language. Examples are in the care plan that you have selected in the Ackley-Ladwig text or care plan constructor site.
A list is also available at the Evolve website. Outcomes are measured along a continuum so they can be measured at any time. They are neutral and may be used to help set goals.
Determine with the client what is appropriate for them. Set times when the outcomes will be measured. You should be able to answer these questions on the slide such as, is it measurable?
Does the client agree with it? Is it realistic? Is there a time frame?
When selecting an outcome it is necessary to consider these questions. All work on the nursing process must be documented. Most agencies and schools have forms to record the information on.
Follow the agency or school guidelines. Interventions may also be selected from a list of standardized nursing language. There are samples with each nursing care plan in the ATCLI-Ladwig text and on the care plan constructor site.
A list is also available on the Evolve site. This slide shows things to think about when selecting interventions. It is an activity done for and with the client.
It will help accomplish the outcomes that were selected. It changes the related factors that were contributing to the nursing diagnosis. The activities are individualized for the client. They are specific so everyone caring for the client knows exactly what to do for them.
They are also safe and will not cause harm to the client. Intervention is a roadmap to guide nursing care. The more clearly a nurse writes an intervention, the easier it will be to complete the journey and arrive at the destination of successful client outcomes. Ideally, interventions should be prescriptive in nature and explicitly state the nursing care to be provided. There are many additional interventions in the Ackley-Ladwig text and in the care plan constructor.
Select ones that are appropriate to your client. Consider the evidence when selecting interventions. Is this a valid intervention for this client in this situation?
Does the research support it? Critical thinking questions to ask include those listed on the slide such as what equipment is needed? Who will assist the client? How often should the intervention be done? The clearer the intervention the easier it will be for all people caring for the client to follow the same protocol.
When you have selected the interventions they need to be documented on the plan of care. Step 4, implementation. Here is where you actually get to act. The implementation phase is where the nurse actually gives care to the client. Some critical thinking questions to ask include, how did the client tolerate the intervention?
Was the time frame appropriate? Were the appropriate personnel involved? These answers will help determine the effectiveness of the nursing care delivered.
Step 5, evaluation. This is a very important part. How did you do?
How is the client? This is the last step of the nursing process. It is listed as last, but it happens continuously as you are delivering care.
If a client were not tolerating an intervention, you would not wait until you were done to stop the activity. Some critical thinking questions to ask when checking client outcomes includes, were the outcomes satisfactory? Is an additional assessment needed?
And were the outcomes realistic? Is the plan of care working? Reassess and determine whether the evidence-based practice interventions that were followed were effective. Necessary revisions may be made at this time.
Remember the acronym ADPAI, Assessment, Diagnosis, Planning, Implementation, and Evaluation. Great work. You've mastered the nursing process and have delivered safe, effective care to your client. You should be proud of your work and of your profession.
This information was referenced from the following sources. If you have questions about any of the content presented in these slides, please talk with your assigned professor. Thank you.