The nursing process is constantly changing, so be sure to keep on top of how to be the best nurse possible. The basic process, however, remains the same. An interesting titbit that you likely will not have to memorize (wink, wink) is that the nursing process was defined by the Catholic University of America in 1967.
The nursing process surrounds patient information, actual and potential health-related issues, planning to resolve or intervene said problems, using the plan you’ve created, evaluating its effectiveness, and adapting the plan as needed.
Allow me to introduce an initialism that will surely drive you insane shortly: ADPIE.
- Assessment (collect history, signs, symptoms, etc.)
- Diagnosis (of existing or potential issues)
- Planning (for prevention or treatment)
- Implementation (Use your plan!)
- Evaluation (Important! Evaluate how the plan is working. Change as needed.)
Assessment
This step consists of two main sources of data: Subjective and objective.
Subjective… What the patient informs you of is subjective. It is information you cannot quantify. You can’t see it, smell it, taste it (ew), feel it, or measure it in any way. Subjective data mainly includes verbal history, symptoms, and perhaps history or information given to you by family members. A good example is “I have a burning pain in my right big toe.” You can’t see the pain, but you have the subjective data now given to you by your patient or client.
You can gather subjective information through interviews. Get your patient’s history. Name, phone number, marital status, address, history of ailments, occupation, alcohol or tobacco use, environmental history (worked with chemicals? Lived near radiation? Areas of pollution?), History of family health (cancers, diseases, etc.), reason for visit today or main health concern.
Objective… data includes things you can witness. They are observable and tend to be things you can measure, such as the length of a wound. Its colour, shape, odour, drainage/exudate characteristics, length, and so forth.
You can obtain objective information by doing a physical assessment, using your patient as your guide. A head-to-toe assessment is usually used, or a review of systems. This will come later in your nursing education.
It is our duty to record all objective and subjective information.
Diagnosis
These are “nursing diagnosis,” so we are not giving them actual diagnosis like a doctor or nurse practitioner would be able to do. This is not within our scope.
In this step of the nursing process, we are stating “risk of” whatever our concern is and then applying it to the potential cause, or… “related to.”
A good one is “risk of skin break-down related to decreased mobility.”
A medical diagnosis could be “stroke/cerebrovascular accident (CVA),” which could cause the decreased mobility, however, we are not to use this diagnosis as this is a medical diagnosis. Ours would include potential or actual nursing diagnosis related to the side effects of this medical diagnosis. Risk of contractures due to decreased mobility. Risk of skin break down due to decreased mobility. Risk of depression due to decreased independence related to loss of movement in left side…
Planning
You are to plan actions that you can provide within your scope as a nurse. In order to decrease the potential for skin breakdown related to decreased mobility, we can make sure that the client is helped into a new position every 2 hours.
Implementation and Evaluation:
Assessment: Medical diagnosis of CVA with left-sided hemiplagia.
Diagnosis: Risk of skin breakdown related to decreased movement (or related to decreased sensation).
Planning: Turn client or reposition every two hours to reduce pressure on skin and encourage blood flow.
Implementation: Do it!
Evaluation: Were you able to implement the plan well or were there things that stood in the way (time, client unwilling, etc.)? Which ones did the client respond well to? Was it successful? Can it be improved?