Nursing Process: Assessment Phase

Nursing Process

• Nursing Process is a systematic and dynamic method used to provide individualized care to patients.

Phases of Nursing Process

• Consists of five distinct phases: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE).

Assessment

• First step of the nursing process that collects data.
• Data collection methods: interview, physical examination, review of medical records, and lab reports.
• Goal is to gather relevant information from sources: patient, family members, healthcare team, and medical records.
• Cues: data obtained through senses (e.g. patient coughing and wheezing).
• Inference: interpretation of the cues (e.g. difficulty breathing).
• Data types: subjective (verbal descriptions) and objective (observations or measurements).

Diagnosis

• Analyzes the collected data to identify patient's actual or potential health problem.
• NANDA diagnosis is not a medical diagnosis, but an actual nursing diagnosis that identifies existing health problems or conditions.
• Three types of nursing diagnosis: actual, risk, and wellness.

Planning

• Involves setting goals to address the problem once diagnosis is identified.
• Collaborates with patient and healthcare team to develop plan of care.
• Plan of care should be specific, measurable, achievable, realistic, and time-bound (SMART).

Implementation

• Puts the plan of care into action by implementing interventions and strategies.
• Types of nursing interventions: independent, dependent, and collaborative.
• Examples of implementation: providing direct patient care, administering medications, performing treatments, teaching patients and families, and coordinating care with other healthcare providers.
• Handoff reporting: transferring essential information from one nurse to the next during transition of care.
• Direct care: treatments performed through interactions with patients.
• Indirect care: performed away from a patient (e.g. safety and infection control).

Evaluation

• Evaluates the patient's response to interventions and the effectiveness of the plan of care.
• Determines whether goals have been achieved.