Nursing Process Made Easy: A Practical Approach for New Nurses

The Nursing Process 101

The acronym ADPIE is perhaps the most recited in nursing school. It stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation. This is the nursing process, which is defined as a systematic plan based on patient-centered and evidenced-based care, administered to a patient to attain health success.

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The nursing process is fragmented into five steps as elaborated by the acronym ADPIE. Introduced into public healthcare education in 1961 as the Deliberative Nursing Process Theory by Ida Jean Orlando, the nursing process has attained international acclamation as the ultimate guide to systemic administration of healthcare. Since 1961 the process has remained intact; very simple yet so complex to eradicate any room for risks and losses.

Importance of the Nursing Process

The nursing process is a complete go-to manual for provision. It provides a framework from the onset of the patient’s visitation up to discharge.

Acquisition of background information on the patient for purposes of treating.
Establishment of health risks, hazards, and concerns within a patient.
Determination of the disease mitigation discourse suitable to the patient’s needs.
Preparation of a detailed and successful health care plan.
Eradication of healthcare administration risks due to misinformation.
Evaluation of patients’ progress during and after treatment.

The nursing process is both a deliberate and precautionary plan. Deliberate because it becomes the basic manual to administration of healthcare for patient success, and precautionary because it helps avoid healthcare catastrophes, and prevents the repercussions of errors, omissions, and general mistakes. Healthcare mistakes attract legal retribution that may be costly to the facility but also to the practitioner’s career.

The Nursing Process

ADPIE

Assessment

This is the nurse’s first interaction with the patient. The remaining steps highly depend on assessment, as this stage is dedicated to acquisition of information on every aspect of the patient’s life. Some common types of information collected include:

Medical history of the patient’s past and currently prevailing health conditions,
Social information on the patient’s family and relationship with everyone else. Cultural information is also relinquished at this stage, to allow the nurse premeditated communication amidst prevailing cultural differences/similarities.
Objective data is information acquired from the patient through interaction with the patient’s body. Nurses feel senses of sight, touch, and conduct other processes to get signs necessary for a diagnosis. It is in this stage that blood samples are taken and imaging conducted to establish a diagnosis.

Some information gathering tactics during assessment are:

Patient interview (questions directed to a patient for them to express their feelings and give any information relevant for treatment.
Relative interview – friends and relatives are questioned on how they observe the patient at home.
Other sources include books and the internet.

#Information from the assessment stage should be preserved not just for treatment purposes, but because the patient has that right.

Diagnosis

The second step entails investigation into the specific illness or prevailing health concerns suffered by the patient. While the first step entails collection of data, diagnosis entails the analysis of this data. The following are some of the objectives of diagnosis;

Analyse patient information to arrive at a conclusion, through this the nurse arrives at the illness affecting the patient.
Detect any gaps or irregularities in the information provided by the patient. The resulting discourse would be reporting the irregular responses to the patient and relevant handler. Misinformation is fatal to the patient’s health.
Notice any health concerns not mentioned by the patient.

Nursing diagnosis takes four forms as shown below:

Problem-focused nursing diagnosis, whereby nursing diagnosis is targeted to the specific concern raised by the patient.
Risk nursing diagnosis, whereby diagnosis is targeted to establish health risks.
Health promotion nursing diagnosis focuses on maintaining the patient’s growth of well-being.
Syndrome diagnosis incorporates predictive diagnostics and possible syndromes that may attack.

Diagnosis results in needs that require solutions in the form of interventions.

Preparation

The health care plan is developed at this stage. Other literatures have divided preparation into two; outcomes, and planning. Outcomes are the expectations anticipated by the nurse out of the healthcare plan. These are the SMART goals set by the nurse and set to be achieved through the health care plan to be prepared.

The care plan is a composite document that elaborates the interventions to be taken by the nurse to achieve the set goals for the well-being development of the patient. Registered Nurses (RN’s) are mandated with developing and supervising care plans, although some interventions may be delegated to Licensed Practical Nurses and Nurse Assistants. These plans are documented and permanently maintained so that they are followed by different nurses during shifts, ensuring a congruent and consistent healthcare administration.

Implementation

The plan in writing is now put to work, hospital staff holistically applying the healthcare plan to chip in each with their own interventions. Implementation stage is the administration of healthcare to patients using the stipulated healthcare plan. The following activities take place in the implementation stage:

Distribution of resources for patient care. Some of these resources include supportive equipment, accommodation in the stay will be lengthy, and any other necessary health resources.
Delegation of responsibilities. The nurse establishes the different interventions, and assigns them to different specialists.
Communication. Every step taken by the nurse on behalf of the hospital is communicated to the patient and consent is affirmed.
Documentation. All activities, interventions, and resources used are documented for the record.

Patients are highly monitored during the implementation, and any discordance with the intended expectations are immediately dealt with. These are risks that result from errors and omissions.

Evaluation

Finally, after the patient has been assessed, diagnosed, a plan prepared and implemented, there has to be evaluation on the progress of the patient in reaction to the various interventions used during the implementation stage. Evaluation is also another process which comprises of six steps;

Collection of data on the progress of the patient
Comparison of the collected data with the set objectives and the expected outcomes
Analysis of the patient’s responses to the interventions, and generally activities carried out by the staff to improve the patient’s well-being.
Identifying the key indicators of success or failures in the performance of the patient
Action on the care plan as per the results; to either halt, suspend, continue, or make adjustments to the healthcare plan, and
Planning for discharging the patient from one stage to another.

And the nursing process is done, from the introduction of the patient to the nurse up to the point of discharge. One important aspect stands out, and that is the nurse-patient relationship. Communication is paramount, as it builds a trustworthy rapport between the two, with the patient exhibiting positive responses from treatment care plans.

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