Nursing Process Overview

Study Notes

Nursing is a systematic approach for delivering care, guided by nursing models and philosophies.
It's patient-centered and goal-oriented, utilizing a structured method for care delivery.
The Nursing Process consists of five major steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE).

In 1955, Hall introduced the concepts of care, cure, and core, defining three steps: Observation, Ministration, and Validation.
In 1959, Johnson characterized nursing as enhancing client behavioral functioning.
Orlando identified three key steps in 1961: Client's behavior, nurse's reaction, and nurse's action.
Weidenbach (1963) described it as a series of phases within nursing.
Wiche in 1967 emphasized the interactive process between client and nurse, outlining four steps: Perception, Communication, Interpretation, and Evaluation.
Yura and Walsh (1967) suggested a four-component model known as APIE.

Identifies clients' health statuses and potential problems, establishing care plans.
Aids in decision-making and evaluating potential outcomes.
Acts as a scientific approach for problem-solving within nursing practices.
Establishes a comprehensive database regarding the client’s health concerns and responses.

Dynamic and Cyclical: Influenced by the patient's needs and the healthcare environment. Continues from admission to discharge.
Client-Centered: Recognizes individual client needs and includes them in healthcare decisions.
Goal-Directed: Focuses on achieving individualized goals through collaboration among patients and healthcare teams, emphasizing problem-solving and decision-making.

A continuous and systematic process involving data collection, validation, organization, and documentation.
Initial Nursing Assessment: Conducted shortly after admission to create a complete health database.
Problem-Focused Assessment: Assesses the status of specific problems, such as vital signs in fever cases.
Emergency Assessment: Rapidly evaluates life-threatening situations, focusing on airways, breathing, and circulation.
Time-Elapsed Reassessment: Conducted months after the initial assessment to compare the client’s current health status with previous data.

Involves gathering comprehensive information regarding a client's health status, including health history and lab test results.

Subjective Data: Known only to the patient; includes personal sensations like pain or feelings of worry.
Objective Data: Observable and measurable signs obtained through physical examinations, like blood pressure readings.

Primary Data: Direct information from the client.
Secondary Data: Information obtained from other sources, enhancing understanding of the client's condition.