nursing process problem solving approach

The Nursing Process: A Comprehensive Guide

In 1958, Ida Jean Orlando began developing the nursing process still evident in nursing care today. According to Orlando’s theory, the patient’s behavior sets the nursing process in motion. Through the nurse’s knowledge to analyze and diagnose the behavior to determine the patient’s needs.

Application of the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EBP) recommendations, and nursing intuition, the nursing process functions as a systematic guide to client-centered care with five subsequent steps. These are assessment , diagnosis, planning, implementation, and evaluation ( ADPIE ).

Table of Contents

What is the nursing process.

• What is the purpose of the nursing process? 

Characteristics of the nursing process

Nursing process steps, collecting data, objective data or signs, subjective data or symptoms, verbal data, nonverbal data, primary source, secondary source, tertiary source, health interview, physical examination, observation, validating data, documenting data, 2. diagnosis: “what is the problem” , initial planning, ongoing planning, discharge planning, developing a nursing care plan, behavioral nursing interventions, community nursing interventions, family nursing interventions, health system nursing interventions, physiological nursing interventions, safety nursing interventions, skills used in implementing nursing care, 1. reassessing the client, 2. determining the nurse’s need for assistance, nursing intervention categories, independent nursing interventions, dependent nursing interventions, interdependent nursing interventions, 4. supervising the delegated care, 5. documenting nursing activities, 1. collecting data, 2. comparing data with desired outcomes, 3. analyzing client’s response relating to nursing activities, 4. identifying factors contributing to success or failure, 5. continuing, modifying, or terminating the nursing care plan, 6. discharge planning.

The nursing process is defined as a systematic, rational method of planning that guides all nursing actions in delivering holistic and patient-focused care. The nursing process is a form of scientific reasoning and requires the nurse’s critical thinking to provide the best care possible to the client.

What is the purpose of the nursing process?

The following are the purposes of the nursing process:

• To identify the client’s health status and actual or potential health care problems or needs (through assessment).
• To establish plans to meet the identified needs.
• To deliver specific nursing interventions to meet those needs.
• To apply the best available caregiving evidence and promote human functions and responses to health and illness (ANA, 2010).
• To protect nurses against legal problems related to nursing care when the standards of the nursing process are followed correctly.
• To help the nurse perform in a systematically organized way their practice.
• To establish a database about the client’s health status, health concerns, response to illness, and the ability to manage health care needs.

The following are the unique characteristics of the nursing process: 

• Patient-centered . The unique approach of the nursing process requires care respectful of and responsive to the individual patient’s needs, preferences, and values. The nurse functions as a patient advocate by keeping the patient’s right to practice informed decision-making and maintaining patient-centered engagement in the health care setting.
• Interpersonal . The nursing process provides the basis for the therapeutic process in which the nurse and patient respect each other as individuals, both of them learning and growing due to the interaction. It involves the interaction between the nurse and the patient with a common goal.
• Collaborative . The nursing process functions effectively in nursing and inter-professional teams, promoting open communication, mutual respect, and shared decision-making to achieve quality patient care.
• Dynamic and cyclical .The nursing process is a dynamic, cyclical process in which each phase interacts with and is influenced by the other phases.
• Requires critical thinking . The use of the nursing process requires critical thinking which is a vital skill required for nurses in identifying client problems and implementing interventions to promote effective care outcomes.

The nursing process consists of five steps: assessment, diagnosis, planning, implementation, and evaluation. The acronym ADPIE is an easy way to remember the components of the nursing process. Nurses need to learn how to apply the process step-by-step. However, as critical thinking develops through experience, they learn how to move back and forth among the steps of the nursing process.

The steps of the nursing process are not separate entities but overlapping, continuing subprocesses. Apart from understanding nursing diagnoses and their definitions, the nurse promotes awareness of defining characteristics and behaviors of the diagnoses, related factors to the selected nursing diagnoses, and the interventions suited for treating the diagnoses.

The steps of the nursing process are detailed below:

1. Assessment: “What data is collected?”

The first phase of the nursing process is assessment . It involves collecting, organizing, validating, and documenting the clients’ health status. This data can be obtained in a variety of ways. Usually, when the nurse first encounters a patient, the nurse is expected to assess to identify the patient’s health problems as well as the physiological, psychological, and emotional state and to establish a database about the client’s response to health concerns or illness and the ability to manage health care needs. Critical thinking skills are essential to the assessment, thus requiring concept-based curriculum changes.

Data collection is the process of gathering information regarding a client’s health status. The process must be systematic and continuous in collecting data to prevent the omission of important information concerning the client.

The best way to collect data is through head-to-toe assessment. Learn more about it at our guide: Head to Toe Assessment: Complete Physical Assessment Guide

Types of Data

Data collected about a client generally falls into objective or subjective categories, but data can also be verbal and nonverbal. 

Objective data are overt, measurable, tangible data collected via the senses, such as sight, touch, smell, or hearing, and compared to an accepted standard, such as vital signs, intake and output , height and weight, body temperature, pulse, and respiratory rates, blood pressure, vomiting , distended abdomen, presence of edema , lung sounds, crying, skin color, and presence of diaphoresis.

Subjective data involve covert information, such as feelings, perceptions, thoughts, sensations, or concerns that are shared by the patient and can be verified only by the patient, such as nausea , pain , numbness, pruritus, attitudes, beliefs, values, and perceptions of the health concern and life events.

Verbal data are spoken or written data such as statements made by the client or by a secondary source. Verbal data requires the listening skills of the nurse to assess difficulties such as slurring, tone of voice, assertiveness, anxiety , difficulty in finding the desired word, and flight of ideas.

Nonverbal data are observable behavior transmitting a message without words, such as the patient’s body language, general appearance, facial expressions, gestures, eye contact, proxemics (distance), body language, touch, posture, clothing. Nonverbal data obtained can sometimes be more powerful than verbal data, as the client’s body language may not be congruent with what they really think or feel. Obtaining and analyzing nonverbal data can help reinforce other forms of data and understand what the patient really feels.

Sources of Data

Sources of data can be primary, secondary, and tertiary . The client is the primary source of data, while family members, support persons, records and reports, other health professionals, laboratory and diagnostics fall under secondary sources.

The client is the only primary source of data and the only one who can provide subjective data. Anything the client says or reports to the members of the healthcare team is considered primary.

A source is considered secondary data if it is provided from someone else other than the client but within the client’s frame of reference. Information provided by the client’s family or significant others are considered secondary sources of data if the client cannot speak for themselves, is lacking facts and understanding, or is a child. Additionally, the client’s records and assessment data from other nurses or other members of the healthcare team are considered secondary sources of data.

Sources from outside the client’s frame of reference are considered tertiary sources of data . Examples of tertiary data include information from textbooks, medical and nursing journals, drug handbooks, surveys, and policy and procedural manuals.

Methods of Data Collection

The main methods used to collect data are health interviews, physical examination, and observation.

The most common approach to gathering important information is through an interview. An interview is an intended communication or a conversation with a purpose, for example, to obtain or provide information, identify problems of mutual concern, evaluate change, teach, provide support, or provide counseling or therapy. One example of the interview is the nursing health history, which is a part of the nursing admission assessment. Patient interaction is generally the heaviest during the assessment phase of the nursing process so rapport must be established during this step.

Aside from conducting interviews, nurses will perform physical examinations, referencing a patient’s health history, obtaining a patient’s family history, and general observation can also be used to gather assessment data. Establishing a good physical assessment would, later on, provide a more accurate diagnosis, planning, and better interventions and evaluation.

Observation is an assessment tool that depends on the use of the five senses (sight, touch, hearing, smell, and taste) to learn information about the client. This information relates to characteristics of the client’s appearance, functioning, primary relationships, and environment. Although nurses observe mainly through sight, most of the senses are engaged during careful observations such as smelling foul odors, hearing or auscultating lung and heart sounds and feeling the pulse rate and other palpable skin deformations.

Validation is the process of verifying the data to ensure that it is accurate and factual. One way to validate observations is through “double-checking,” and it allows the nurse to complete the following tasks:

• Ensures that assessment information is double-checked, verified, and complete. For example, during routine assessment, the nurse obtains a reading of 210/96 mm Hg of a client with no history of hypertension . To validate the data, the nurse should retake the blood pressure and if necessary, use another equipment to confirm the measurement or ask someone else to perform the assessment.
• Ensure that objective and related subjective data are valid and accurate. For example, the client’s perceptions of “feeling hot” need to be compared with the measurement of the body temperature.
• Ensure that the nurse does not come to a conclusion without adequate data to support the conclusion. A nurse assumes tiny purple or bluish-black swollen areas under the tongue of an older adult client to be abnormal until reading about physical changes of aging.
• Ensure that any ambiguous or vague statements are clarified. For example, a 86-year-old female client who is not a native English speaker says that “I am in pain on and off for 4 weeks,” would require verification for clarity from the nurse by asking “Can you describe what your pain is like? What do you mean by on and off?”
• Acquire additional details that may have been overlooked. For example, the nurse is asking a 32-year-old client if he is allergic to any prescription or non-prescription medications. And what would happen if he takes these medications.
• Distinguish between cues and inferences. Cues are subjective or objective data that can be directly observed by the nurse; that is, what the client says or what the nurse can see, hear, feel, smell, or measure. On the other hand, inferences are the nurse’s interpretation or conclusions made based on the cues. For example, the nurse observes the cues that the incision is red, hot, and swollen and makes an inference that the incision is infected.

Once all the information has been collected, data can be recorded and sorted. Excellent record-keeping is fundamental so that all the data gathered is documented and explained in a way that is accessible to the whole health care team and can be referenced during evaluation. 

The second step of the nursing process is the nursing diagnosis . The nurse will analyze all the gathered information and diagnose the client’s condition and needs. Diagnosing involves analyzing data, identifying health problems, risks, and strengths, and formulating diagnostic statements about a patient’s potential or actual health problem. More than one diagnosis is sometimes made for a single patient. Formulating a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care.

The types, components, processes, examples, and writing nursing diagnosis are discussed more in detail here “ Nursing Diagnosis Guide: All You Need To Know To Master Diagnosing ”

3. Planning: “How to manage the problem?”

Planning is the third step of the nursing process. It provides direction for nursing interventions. When the nurse, any supervising medical staff, and the patient agree on the diagnosis, the nurse will plan a course of treatment that takes into account short and long-term goals. Each problem is committed to a clear, measurable goal for the expected beneficial outcome. 

The planning phase is where goals and outcomes are formulated that directly impact patient care based on evidence-based practice (EBP) guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum.

Types of Planning

Planning starts with the first client contact and resumes until the nurse-client relationship ends, preferably when the client is discharged from the health care facility.

Initial planning is done by the nurse who conducts the admission assessment. Usually, the same nurse would be the one to create the initial comprehensive plan of care.

Ongoing planning is done by all the nurses who work with the client. As a nurse obtain new information and evaluate the client’s responses to care, they can individualize the initial care plan further. An ongoing care plan also occurs at the beginning of a shift. Ongoing planning allows the nurse to:

• determine if the client’s health status has changed
• set priorities for the client during the shift
• decide which problem to focus on during the shift
• coordinate with nurses to ensure that more than one problem can be addressed at each client contact

Discharge planning is the process of anticipating and planning for needs after discharge. To provide continuity of care, nurses need to accomplish the following:

• Start discharge planning for all clients when they are admitted to any health care setting.
• Involve the client and the client’s family or support persons in the planning process.
• Collaborate with other health care professionals as needed to ensure that biopsychosocial, cultural, and spiritual needs are met.

A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans provide communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, the quality and consistency of patient care would be lost.

The planning step of the nursing process is discussed in detail in Nursing Care Plans (NCP): Ultimate Guide and Database .

4. Implementation: “Putting the plan into action!”

The implementation phase of the nursing process is when the nurse puts the treatment plan into effect. It involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This typically begins with the medical staff conducting any needed medical interventions. 

Interventions should be specific to each patient and focus on achievable outcomes. Actions associated with a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient or conducting important medical tasks such as medication administration , educating and guiding the patient about further health management, and referring or contacting the patient for a follow-up.

A taxonomy of nursing interventions referred to as the Nursing Interventions Classification (NIC) taxonomy, was developed by the Iowa Intervention Project. The nurse can look up a client’s nursing diagnosis to see which nursing interventions are recommended. 

Nursing Interventions Classification (NIC) System

There are more than 550 nursing intervention labels that nurses can use to provide the proper care to their patients. These interventions are categorized into seven fields or classes of interventions according to the Nursing Interventions Classification system.

These are interventions designed to help a patient change their behavior. With behavioral interventions, in contrast, patient behavior is the key and the goal is to modify it. The following measures are examples of behavioral nursing interventions:

• Encouraging stress and relaxation techniques
• Providing support to quit smoking
• Engaging the patient in some form of physical activity , like walking, to reduce the patient’s anxiety, anger, and hostility

These are interventions that refer to the community-wide approach to health behavior change. Instead of focusing mainly on the individual as a change agent, community interventionists recognize a host of other factors that contribute to an individual’s capacity to achieve optimal health, such as:

• Implementing an education program for first-time mothers
• Promoting diet and physical activities
• Initiating HIV awareness and violence-prevention programs
• Organizing a fun run to raise money for breast cancer research 

These are interventions that influence a patient’s entire family.

• Implementing a family-centered approach in reducing the threat of illness spreading when one family member is diagnosed with a communicable disease
• Providing a nursing woman support in breastfeeding her new baby
• Educating family members about caring for the patient

These are interventions that designed to maintain a safe medical facility for all patients and staff, such as:

• Following procedures to reduce the risk of infection for patients during hospital stays.
• Ensuring that the patient’s environment is safe and comfortable, such as repositioning them to avoid pressure ulcers in bed

These are interventions related to a patient’s physical health to make sure that any physical needs are being met and that the patient is in a healthy condition. These nursing interventions are classified into two types: basic and complex.

• Basic. Basic interventions regarding the patient’s physical health include hands-on procedures ranging from feeding to hygiene assistance.
• Complex. Some physiological nursing interventions are more complex, such as the insertion of an IV line to administer fluids to a dehydrated patient.

These are interventions that maintain a patient’s safety and prevent injuries, such as:

• Educating a patient about how to call for assistance if they are not able to safely move around on their own
• Providing instructions for using assistive devices such as walkers or canes, or how to take a shower safely.

When implementing care, nurses need cognitive, interpersonal, and technical skills to perform the care plan successfully.

• Cognitive Skills are also known as Intellectual Skills are skills involve learning and understanding fundamental knowledge including basic sciences, nursing procedures, and their underlying rationale before caring for clients. Cognitive skills also include problem-solving, decision-making, critical thinking, clinical reasoning, and creativity.
• Interpersonal Skills are skills that involve believing, behaving, and relating to others. The effectiveness of a nursing action usually leans mainly on the nurse’s ability to communicate with the patient and the members of the health care team.
• Technical Skills are purposeful “hands-on” skills such as changing a sterile dressing, administering an injection, manipulating equipment, bandaging, moving, lifting, and repositioning clients. All of these activities require safe and competent performance.

Process of Implementing

The process of implementing typically includes the following:

Prior to implementing an intervention, the nurse must reassess the client to make sure the intervention is still needed. Even if an order is written on the care plan, the client’s condition may have changed.

Other nursing tasks or activities may also be performed by non-RN members of the healthcare team. Members of this team may include unlicensed assistive personnel (UAP) and caregivers , as well as other licensed healthcare workers, such as licensed practical nurses/licensed vocational nurses (LPNs/LVNs). The nurse may need assistance when implementing some nursing intervention, such as ambulating an unsteady obese client, repositioning a client, or when a nurse is not familiar with a particular model of traction equipment needs assistance the first time it is applied.

3. Implementing the nursing interventions

Nurses must not only have a substantial knowledge base of the sciences, nursing theory , nursing practice, and legal parameters of nursing interventions but also must have the psychomotor skills to implement procedures safely. It is necessary for nurses to describe, explain, and clarify to the client what interventions will be done, what sensations to anticipate, what the client is expected to do, and what the expected outcome is. When implementing care, nurses perform activities that may be independent, dependent, or interdependent.

Nursing interventions are grouped into three categories according to the role of the healthcare professional involved in the patient’s care:

A registered nurse can perform independent interventions on their own without the help or assistance from other medical personnel, such as: 

• routine nursing tasks such as checking vital signs
• educating a patient on the importance of their medication so they can administer it as prescribed

A nurse cannot initiate dependent interventions alone. Some actions require guidance or supervision from a physician or other medical professional, such as:

• prescribing new medication
• inserting and removing a urinary catheter
• providing diet
• Implementing wound or bladder irrigations

A nurse performs as part of collaborative or interdependent interventions that involve team members across disciplines.

• In some cases, such as post- surgery , the patient’s recovery plan may require prescription medication from a physician, feeding assistance from a nurse, and treatment by a physical therapist or occupational therapist.
• The physician may prescribe a specific diet to a patient. The nurse includes diet counseling in the patient care plan. To aid the patient, even more, the nurse enlists the help of the dietician that is available in the facility.

Delegate specific nursing interventions to other members of the nursing team as appropriate. Consider the capabilities and limitations of the members of the nursing team and supervise the performance of the nursing interventions. Deciding whether delegation is indicated is another activity that arises during the nursing process.

The American Nurses Association and the National Council of State Boards of Nursing (2006) define delegation as “the process for a nurse to direct another person to perform nursing tasks and activities.” It generally concerns the appointment of the performance of activities or tasks associated with patient care to unlicensed assistive personnel while retaining accountability for the outcome.

Nevertheless, registered nurses cannot delegate responsibilities related to making nursing judgments. Examples of nursing activities that cannot be delegated to unlicensed assistive personnel include assessment and evaluation of the impact of interventions on care provided to the patient.

Record what has been done as well as the patient’s responses to nursing interventions precisely and concisely.

5. Evaluation: “Did the plan work?”

Evaluating is the fifth step of the nursing process. This final phase of the nursing process is vital to a positive patient outcome. Once all nursing intervention actions have taken place, the team now learns what works and what doesn’t by evaluating what was done beforehand. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. The possible patient outcomes are generally explained under three terms: the patient’s condition improved, the patient’s condition stabilized, and the patient’s condition worsened.

Steps in Evaluation

Nursing evaluation includes (1) collecting data, (2) comparing collected data with desired outcomes, (3) analyzing client’s response relating to nursing activities, (4) identifying factors that contributed to the success or failure of the care plan, (5) continuing, modifying, or terminating the nursing care plan, and (6) planning for future nursing care.

The nurse recollects data so that conclusions can be drawn about whether goals have been fulfilled. It is usually vital to collect both objective and subjective data. Data must be documented concisely and accurately to facilitate the next part of the evaluating process.

The documented goals and objectives of the nursing care plan become the standards or criteria by which to measure the client’s progress whether the desired outcome has been met, partially met, or not met.

• The goal was met , when the client response is the same as the desired outcome.
• The goal was partially met , when either a short-term outcome was achieved but the long-term goal was not, or the desired goal was incompletely attained.
• The goal was not met.

It is also very important to determine whether the nursing activities had any relation to the outcomes whether it was successfully accomplished or not.

It is required to collect more data to confirm if the plan was successful or a failure. Different factors may contribute to the achievement of goals. For example, the client’s family may or may not be supportive, or the client may be uncooperative to perform such activities. 

The nursing process is dynamic and cyclical. If goals were not sufficed, the nursing process begins again from the first step. Reassessment and modification may continually be needed to keep them current and relevant depending upon general patient condition. The plan of care may be adjusted based on new assessment data. Problems may arise or change accordingly. As clients complete their goals, new goals are set. If goals remain unmet, nurses must evaluate the reasons these goals are not being achieved and recommend revisions to the nursing care plan.

Discharge planning is the process of transitioning a patient from one level of care to the next. Discharge plans are individualized instructions provided as the client is prepared for continued care outside the healthcare facility or for independent living at home. The main purpose of a discharge plan is to improve the client’s quality of life by ensuring continuity of care together with the client’s family or other healthcare workers providing continuing care.

The following are the key elements of IDEAL discharge planning according to the Agency for Healthcare Research and Quality:

• I nclude the patient and family as full partners in the discharge planning process.
• Describe what life at home will be like
• Review medications
• Highlight warning signs and problems
• Explain test results
• Schedule follow-up appointments
• E ducate the patient and family in plain language about the patient’s condition, the discharge process, and next steps throughout the hospital stay.
• A ssess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient’s care to the patient and family and use teach back.
• L isten to and honor the patient’s and family’s goals, preferences, observations, and concerns. 

A discharge plan includes specific components of client teaching with documentation such as:

• Equipment needed at home. Coordinate home-based care and special equipment needed.
• Dietary needs or special diet . Discuss what the patient can or cannot eat at home.
• Medications to be taken at home. List the patient’s medications and discuss the purpose of each medicine, how much to take, how to take it, and potential side effects.
• Resources such as contact numbers and addresses of important people. Write down the name and contact information of someone to call if there is a problem.
• Emergency response: Danger signs. Identify and educate patients and families about warning signs or potential problems.
• Home care activities. Educate patient on what activities to do or avoid at home.
• Summary. Discuss with the patient and family about the patient’s condition, the discharge process, and follow-up checkups.

39 thoughts on “The Nursing Process: A Comprehensive Guide”

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You can download the articles by printing them as PDF :) You can use a service called printfriendly (google it) to make PDFs of our webpages.

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Thank you so much, Alisa. If you need more information or help regarding this, let us know.

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Hi Millicent, Thank you so much for the kind words! 😊 I’m really glad you’re finding the site useful.

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The 5 Nursing Process Steps – (Learn Each Step in Detail)

One of the most important tools a nurse can use in practice is the nursing process. Although nursing schools teach first-year students about the nursing process, some nurses fail to grasp the impact its proper use can have on patient care. In this article, I will share information about the nursing process, its history, its purpose, its main characteristics, and the 5 steps involved in carrying out the nursing process. After reading this article, you will be able to answer the question, “what is the nursing process” and understand what is involved in each of the 5 steps of the nursing process. Additionally, throughout this article, after discussing a step of the nursing process, I will share an example of how the nurse would proceed with that step. For this article’s purposes, we will use information about the following patient: Mr. Collie, a fifty-four-year-old white male being admitted to the Medical-Surgical floor for acute congestive heart failure.

What Is The Nursing Process In Simple Words?

When was the nursing process developed, who developed the nursing process, what is the purpose of the nursing process, what are the 7 main characteristics of the nursing process, 1. within the legal scope of practice, 2. based on sound knowledge, 4. client-centered, 5. goal-directed, 6. prioritized, 7. dynamic and cyclical, how many steps are there in the nursing process, what are the 5 steps of the nursing process, step #1: assessment phase, step #2: diagnosis phase, step #3: planning phase, step #4: implementation phase, step #5: evaluation phase, useful resources to gain more information about the nursing process, blogs/websites, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. how is nursing process different from the scientific method, 2. do all nurses use the nursing process, 3. do doctors also use the nursing process, 4. what does adpie stand for, 5. is it always necessary for a nurse to follow all steps of the nursing process, 6. how does critical thinking impact the nursing process, 7. how does a health information system affect the nursing process, 8. how to use maslow hierarchy in the nursing process, 9. which nursing process step includes tasks that can be delegated, 10. which nursing process step includes tasks that cannot be delegated, 11. how does the nursing process apply to pharmacology.

ADPIE – The Five Stages of The Nursing Process

ADPIE is an acronym for assessment, diagnosis, planning, implementation, and evaluation.

The ADPIE process helps medical professionals remember the process and order of the steps they need to take to provide proper care for the individuals they are treating.

This process is essential as it provides a practical and thorough framework for patient care.

It also helps medical professionals develop critical thinking and problem-solving skills.

By following the ADPIE process, medical professionals can improve their work efficiency and promptly develop more accurate decisions.

Process Overview

The purpose of ADPIE is to help improve an individual’s mental, emotional, and physical health through analysis, diagnosis, and treatment.

The ADPIE process allows medical professionals to identify potential problems, develop solutions, and monitor the results individually.

Nurses must reevaluate, adjust and correct the process if it does not improve the patient’s condition.

Here is an explanation detailing each step of the process:

Assessment is the first step of the ADPIE process.

During the assessment phase, medical professionals will attempt to identify the problem and establish a database.

Interviewing the patient and family members, observing behavior, and performing examinations help with the assessment.

This step focuses heavily on collecting/recording data, validating information, and listing any abnormalities in the data.

Nurses collect assessment data in one of two ways, subjective or objective.

You cannot measure subjective data directly.

It includes verbal information like asking questions, obtaining verbal feedback, interviewing people, and collecting/gathering a patient’s health history data.

Subjective data is symptomatic because nurses cannot measure or observe it directly.

Objective data is measurable because nurses can see, hear, feel, or smell it.

It includes measuring a patient’s weight, blood pressure, heart rate, and body temperature.

Because objective data is measurable, nurses refer to it as signs.

Gathering as much data as possible during the assessment phase is essential.

While gathering data, Identify if the data is accurate, concise, consistent, and straightforward.

Once you’ve gathered enough accurate data, you can form a conclusion about the patient’s condition.

After that, move on to the next phase of the ADPIE process, diagnosis.

The process’s diagnosis phase is where the medical professional develops a theory or hypothesis about the individual’s situation based on the information collected while performing an assessment.

Although registered nurses cannot form a professional diagnosis, they can develop critical thinking and communicate their clinical judgments to their team members.

Nurses have a standardized language for communicating their clinical judgments, which comes from NANDA international .

That said, certified nurse practitioners can diagnose medical conditions and act as primary care providers for their patients.

Examples of Medical Language Nurse Use Include:

• Activity intolerance
• Constipation
• Decreased cardiac output
• Fluid volume deficit
• Hypothermia
• Sleep deficit

The diagnostic process allows medical professionals to decide on the individual they treat.

That determination determines whether the patient is dealing with a physiological, mental, or emotional condition.

And while nurses cannot give a professional diagnosis , they can identify actual or potential medical /health risks.

After performing a diagnosis, nurses must place risks that can cause complications or harm in order.

Organize the highest risks as the top priority (life-threatening).

Accordingly, nurses should label lower risks in descending order (non-life-threatening/minor/future well-being).

Nurses must identify, address and correct new problems that affect other priorities.

Therefore, nurses must perform assessments regularly to approach patient problems adequately.

After identifying and prioritizing the concerns, the next phase of the process is planning.

Planning involves developing a plan and establishing SMART goals to achieve the desired outcome.

For example, adequate planning helps reduce a patient’s pain or improve cardiovascular function.

SMART goals are specific, measurable, attainable, realistic/relevant, and time-restricted.

SMART goals provide the individual with focused activities designed to improve their condition.

They also provide medical professionals with a plan to measure and evaluate the individual’s improvements.

Goals may be short-term or long-term, singular in nature, and focus on the individual outcome.

Nurses must determine whether the SMART goals benefit the patient.

They must also make sure that the SMART goals are attainable.

In addition to SMART goals, nurses must develop and communicate a care plan and intervention strategies to the team.

It helps maximize the success of the goals.

The care plan involves the steps and strategies needed to achieve the desired goal.

Along with the care plan, developing intervention strategies keeps the individual on track.

Nurses communicate the care plan and intervention strategies to the patient and medical team as part of the treatment.

After nurses establish the care plan, interventions, and SMART goals, they must implement them into patient care.

Implementation

The implementation phase is the actionable part of the process.

It’s where the medical team implements the care plan, SMART goals, and interventions to achieve their goals.

Accordingly, nurses can evaluate and measure this process.

The implementation phase uses a combination of direct care and indirect care.

Direct care involves giving patients physical or verbal aid.

Direct care includes assisting the patient with mobility, performing physical maintenance, range of motion exercises, and assisting with daily living activities.

It may also include coaching, counseling, and providing feedback to the individual.

Indirect care involves actions performed while away from the patient.

Indirect care may include monitoring/supervising the medical staff, delegating responsibilities, and advocating on behalf of the patients.

While implementing the care plan, the nurse/team needs to use critical judgment.

They must also question care plan procedures to ensure it meets the demands/concerns of the people receiving the care.

Steps or procedures that appear inappropriate, non-actionable, or questionable should be questioned and reevaluated with the medical staff. 

Moreover, nurses must communicate with those receiving the care plan to ensure it is safe and aligns with the medical teams/individuals’ goals.

The last phase of the process is the evaluation phase.

It’s where the medical professionals assess and evaluate the success of the planning and implementation processes.

This phase ensures that the individual is making progress towards their goals and is achieving the desired outcome.

Healthcare professionals must evaluate if the process works and identify what brings the individual closer to their goals.

Nurses must reassess the problem if it isn’t working and determine whether it needs to be modified or eliminated.

Nurses must regularly perform evaluations during the ADPIE process to assess the plan and make adjustments.

By performing regular evaluations, medical professionals can determine the appropriate course of action, identify potential errors, and ensure that the process works as smoothly as possible.

ADPIE Recap

The ADPIE process assists medical professionals in identifying and addressing potential medical concerns.

By implementing the process, medical professionals can assess the patient’s condition and ensure they receive adequate care.

The assessment process begins through the collection of subjective and objective data.

This data allows medical to develop a diagnosis based on the collected information.

With the diagnosis, nurses can create a plan with interventions and SMART goals for the patient to follow.

The process is then implemented into action to achieve the plan’s goals.

Nurses must evaluate the process during and after implementation to ensure the individual achieves their goals.

ADPIE is an excellent way to improve critical thinking.

It helps nurses create, evaluate, and reevaluate procedures.

It also helps them implement and modify processes until they reach the desired outcome.

What Are The Five Stages of The Nursing Process?

The five stages of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.

In other words, the five stages of the nursing process are ADPIE, which I explained earlier in this article.

Nurses follow these five stages to ensure proper patient care from the beginning of treatment until the end.

Consequently, It allows nurses to utilize a systematic approach to observing, analyzing, taking action, and reevaluating goals, strategies, and outcomes.

Overall this helps nurses perform their best and account for potential mistakes and errors throughout patient treatment.

The ADPIE nursing process is an essential component of clinical care.

It improves critical thinking and decision-making by breaking down processes into simplified and organized steps.

Each concurrent step builds upon the previous one throughout the process until nurses develop and implement a good approach.

With that said, numerous nurses lack experience applying the ADPIE nursing process.

It’s partially due to a shortage of information/resources and busy work schedules making it difficult to implement.

However, new processes are continually developing, allowing current/future nurses to incorporate these processes into their daily work.

Without processes like ADPIE and others, nurses would have more difficulty approaching complex patient care scenarios.

ADPIE isn’t well known among some nurses.

However, there are many well-known, and implemented processes nurses utilize.

Managing Nursing Care

Cite this chapter.

• Richard Hogston  

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The purpose of this chapter is to explore how nurses manage care; it will take you through a five-stage problem-solving approach known as the nursing process. At the end of the chapter you should be able to:

Define the stages of the nursing process

Undertake a nursing assessment

Identify nursing diagnoses from the assessment data

Devise and implement a plan of care

Evaluate your actions

Consider the link between evaluation and quality of care.

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Hogston, R. (1999). Managing Nursing Care. In: Hogston, R., Simpson, P.M. (eds) Foundations of Nursing Practice. Palgrave, London. https://doi.org/10.1007/978-1-349-14608-6_1

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Home / NCLEX-RN Exam / Integrated Processes: NCLEX-RN

Integrated Processes: NCLEX-RN

The nursing process, communication and documentation, teaching and learning processes.

The NCLEX-RN examination and nursing practice require the nurse to apply the fundamental prin­ciples of clinical decision making and critical thinking to nursing practice. The NCLEX-RN examination "test plan also makes the assumption that the nurse integrates concepts from the following bodies of knowledge:

• Social sciences (psychology and sociology);
• Biological sciences (anatomy, physiology, biology and microbiology); and
• Physical sciences (chemistry and physics)"

The four integrated processes that are tested throughout the NCLEX-RN examination and fundamental to the practice of registered nursing are The Nursing Process, Caring, Communication and Documentation, and Teaching and Learning.

The Nursing Process is defined as the "scientific, clinical reasoning approach to client care that includes assessment, analysis, planning, implementation and evaluation".

Caring is defined as the "interaction of the nurse and client in an atmosphere of mutual respect and trust. In this col­laborative environment, the nurse provides encouragement, hope, support and compassion to help achieve desired outcomes."

Communication and Documentation is defined as the verbal and nonverbal interactions between the nurse and the client, the client's significant others and other members of the health care team. Events and activities associated with client care are recorded and documented in written and/or electronic records that demonstrate adher­ence to the standards of practice and accountability in the provision of care. This documentation is a form of written communication."

Teaching/Learning is defined as the "facilitation of the acquisition of knowledge, skills and attitudes promoting a change in behavior."

Although many aspects of nursing, and the knowledge needed, for both registered nurses and licensed practical or vocational nurses are similar, there are also some major differences.

The Clinical Problem Solving Process and the Nursing Process is one of these major differences.

RN’s use the Clinical Problem Solving Process to guide their thinking and problem solving and registered nurses use the Nursing Process to guide their thinking, professional judgment, critical thinking and their problem solving when it comes to patient care.

The Clinical Problem Solving Process that is used by the licensed/practical or vocational nurse is a scientific process that includes data collection, planning, implementation and evaluation. On the other hand, the Nursing Process that is used by the professional registered nurse is a scientific, dynamic and cyclical process that includes assessment, data analysis, planning, implementation and evaluation.

The Nursing Process is defined as the "scientific, clinical reasoning approach to client care that includes assessment, analysis, planning, implementation and evaluation", according to the National Council of State Boards of Nursing.

Although the National Council of State Boards of Nursing defines the components of the Nursing Process as assessment, analysis, planning, implementation and evaluation, the data analysis phase of the Nursing Process additionally includes the generation of a nursing diagnosis as based on the analysis of the data that were collected during the assessment phase of the Nursing Process are:

• Data Collection
• Data Organization and Analysis
• Nursing Diagnosis
• Implementation

The nursing process is a goal directed, systematic, ongoing cyclical, dynamic, goal directed problem solving approach to nursing care.

This process has a series of interrelated and interconnected phases that move cyclically, smoothly and coherently toward meeting the needs of our clients and/or their significant others. Each phase of this process is affected by and impacted with all of the other phases of the Nursing Process.

For example, the data that is collected during the assessment phase of the Nursing Process is used for the nursing diagnosis and the planning of client care. When data collected during the assessment phase of the Nursing Process is not current, accurate and/or complete, the nursing diagnosis and the plan of care will not be appropriate because it is impacted with and affected by faulty and incomplete data.

Assessment Phase of the Nursing Process

The Nursing Process begins with the assessment phase of the Nursing Process and this assessment phase must begin during the first client contact and continue throughout the entire course of care. The first client contact data collection and assessment is often referred to as the "Initial Assessment" and the data collection and assessments that are done after the "Initial Assessment" are often referred to as "Ongoing Assessments" or "Re-Assessments".

A newly admitted patient to a medical center will have an initial assessment as soon as they are admitted and this same patient will have re-assessments and ongoing assessments throughout the course of their hospitalization because their condition will change. For example, a client who is admitted to a medical center with chest pain will have a number of diagnostic tests and then even have cardiac surgery. Re-assessments, therefore, are done when the client's condition changes as the result of cardiac treatments, cardiac diagnostic tests, and the surgical procedure that they have during the course of their hospitalization after admission.

Data Collection Phase of the Nursing Process

During the assessment phase of the Nursing Process data that is related to the client, family members and significant others, are collected during the assessment phase of the nursing process and, then, this data is also organized and documented.

The client who is being assessed by the registered nurse can be an individual, family, the community or another group. As you should recall, the definition of a "client" or "patient" is defined as an individual, a family, or a group and a "group" is more than one client or patient. Groups can be defined as populations of people, age groups of people and other groups of people.

The data that are collected during the assessment phase of the Nursing Process can be described and classified in a number of different ways. This assessment data can be described and classified as:

• Current or retrospective, historical data
• Subjective and objective data
• Primary and secondary data
• Qualitative and quantitative data
• Physical, psychological, social, cultural and spiritual data

Current data is described as that data that reflects the current physical, psychological, social, cultural or spiritual condition or status of the client. In contrast, retrospective, historical data reflects the client's past physical, psychological, social, cultural or spiritual condition or status. An example of current data that is collected during the assessment phase of the Nursing Process is the client's current vital signs and the status of their peripheral pulses, for example. An example of retrospective, historical data that is collected during the assessment phase of the Nursing Process is the client's past surgeries and illnesses.

Historical data like that contained in an old medical record gives healthcare providers some information about and insight into the patient's past medical problems. Current data gives us up to date data and information about the patient's current medical status.

Subjective and objective data are defined as that data that is not empirical, and objective data is defined as data that is empirical. Empirical data is defined as that data that can be perceived with our senses and data that is not empirical cannot be confirmed with the senses.

Subjective data includes things that the client, patient or family member says. For example, the client may state, "I have chest pain" or "I am tired all the time" or a family member may state, "My mother has become tearful and depressed after the loss of my father". Many subjective data statements consist of the client's chief complaint and their symptoms.

Subjective data is recorded and documented in the exact and precise words of the person that has made the statement and these words are put into quotation marks.

Objective data, on the other hand, is data that is collected with the senses of the person collecting the objective data. For example, observing and measuring wound drainage, laboratory diagnostic test results, the smelling a fruity breath odor, feeling peripheral pulses and sensing bodily coolness with your finger tips and your tactile senses are examples of objective data that you see, hear, smell and feel.

Subjective data is also recorded and documented in the client's medical record in a factual and objective manner.

There are some occasions when data that is collected during the assessment phase of the Nursing Process is both subjective and objective. For example, a client may state that, "I have soreness on my lower back", which is subjective data, at the same time that the registered nurse assesses the client's back and notices an area of pressure and blanching, which is objective data because the nurse actually sees it.

Primary and secondary data are also collected during the data collection portion of the assessment.

Primary data is data that is collected from the patient themselves; and secondary data that is collected from things other than the patient.

The patient's vital signs, the patent's complaints of pain and the patient's level of balance are examples of primary data. Examples of secondary data include things like laboratory results, the results of x rays and information that is told to the nurse by others like family members.

Qualitative data is defined as data that is NOT numerical and quantitative data is defined as data that is numerical.

Examples of quantitative data are vital signs, diagnostic laboratory test values and the quantity of sputum or wound drainage; and examples of qualitative data include the interpretation of X rays and other radiographic diagnostic tests, a description of a wound in terms of wound drainage color and a narrative patient's past medical history.

Physical or biological data is current and historical data, primary and secondary data, subjective and objective, qualitative and quantitative data that relates to the client's physical and biological status. This data includes data and information about things that are normal and things that are not normal. It also includes data relating to risk factors that can impact on the client's level of health, wellness and illnesses.

Psychological data includes current and historical data, primary and secondary data, subjective and objective, qualitative and quantitative data that relates to the client's psychological, mental and emotional status. This data includes data and information about things that are normal and things that are not normal. It also includes data relating to risk factors that can impact on the client's level of health, wellness and illnesses in terms of their mental and psychological condition.

Social data is data is defined as current and historical data, primary and secondary data, subjective and objective, qualitative and quantitative data that relates to the client's social status. This data includes data and information about things that are normal and things that are not normal relating to the client's social support systems and economic factors, for example. It also includes social data relating to risk factors that can impact on the client's level of health, wellness and illnesses.

Cultural data is data that is defined as current and historical data, primary and secondary data, subjective and objective, qualitative and quantitative data that relates to the client's culture and cultural status. This data includes data and information about the client's cultural beliefs, practices and values that are passed on to the client through the generations of people who share this culture.

Lastly, spiritual data is data that is defined as current and historical data, primary and secondary data, subjective and objective, qualitative and quantitative data that relates to the client's spiritual and/or religious status. This data includes data and information about the client's religious and spiritual beliefs, practices and values that are held by the client.

The registered nurse assesses individuals, groups like families and the local as well as global community to determine their healthcare needs.

Assessment data is collected, in collaboration with the licensed practical nurse and all of the other members of the healthcare team. This data is then organized, validated with the client and others, and finally documented by the registered nurse and other members of the interdisciplinary team.

Some of the data that is particular to the role and responsibility of the registered nurse, when compared and contrasted to the licensed practical nurse, includes a complete and thorough head to toe physical assessment and a complete and thorough history which includes the current and past medical history. The licensed practical nurse can collect some data with the guidance and under the direction of the registered nurse, however, the assessment and data collection processes are the ultimate responsibilities of the registered nurse and not the licensed practical nurse.

Again, data is collected in reference to the physical or biological, psychological or emotional, social, spiritual and cultural characteristics and needs for the whole or holistic client in their environment.

Data Organization and Analysis Phase of the Nursing Process

Data organization and analysis are also the role and responsibility of the registered nurse rather than the licensed practical nurse. Data analysis entails the organization and analysis of data that requires the critical thinking skills and the professional judgment skills that the registered nurse, rather than the licensed practice nurse, is academically prepared to do.

Data is organized by the nurse in a number of possible ways. For example, the nurse can organize the collected assessment data into bodily systems, according to priorities, according to current health care problems and according to past health data that can indicate some risk factors for the client.

The purpose of analyzing the collected and organized assessment data is to identify existing patterns and trends in the data, to compare data to established norms, standards and normal parameters using the knowledge, skills, abilities, inductive and deductive reasoning of the registered nurse which is often done in close collaboration with other members of the healthcare team. After this analysis, the analyzed data is used for conclusions and decision making in terms of the client and their healthcare needs and problems.

For example, if the current patient data indicates that the client is vomiting, has diarrhea, poor fluid intake, scant urinary output, dry mucous membranes, orthostatic hypotension and confusion, the registered nurse would use their professional judgement, critical thinking and reasoning skills to conclude that the patient is likely affected with dehydration. Because this data indicates the presence of dehydration, decisions and planning of care will be based on this analyzed data.

Nursing Diagnosis Phase of the Nursing Process

This diagnosing phase of the nursing process involves the nurse's application of critical thinking to determine the client's health related risk factors, health related concerns and problem, and their strengths and weaknesses in terms of the client's complete biological, psychological, social, cultural and spiritual data.

The generation of nursing diagnoses, after assessment and data analysis, is also the sole responsibility of the registered nurse according to the states' scope of practice for the registered nurse.

Nursing diagnoses are different from medical diagnoses. Nursing diagnoses identify actual and potential healthcare problems and their defining characteristics, rather than a medical diagnosis.

There are several types of nursing diagnoses, including actual diagnoses, risk diagnoses, wellness diagnoses, possible nursing diagnoses, and syndrome nursing diagnoses.

An example of an actual nursing diagnosis is "Ineffective urinary elimination as related to…". An example of a risk nursing diagnosis is "At risk for impaired oxygenation as related to…". An example of a wellness nursing diagnosis is "Readiness for enhanced client education relating to the pathophysiology of diabetes mellitus." Likewise, an example of a possible nursing diagnosis is "Possible anticipatory grief related to…"; and lastly an example of a syndrome nursing diagnosis is "Risk for disuse syndrome related to…"

Nursing diagnoses have several components. The most complete and useful nursing diagnoses consist of a problem or diagnostic statement, a qualifier, the etiology of the healthcare need or concern and the defining characteristics of the healthcare need or concern.

For example, in the nursing diagnosis "Impaired spiritual comfort related to a terminal disease as evidenced by spiritual anxiety and distress", the problem or diagnostic statement is "spiritual comfort, the qualifier is "impaired", the etiology is the presence of a "terminal disease" and the defining characteristic is "as evidenced by spiritual anxiety and distress".

Other than "impaired", other commonly used qualifiers that can and are used in nursing diagnoses are:

• Ineffective
• Imbalanced and
• Compromised

Depending on your organization's policies and procedures, nursing diagnoses may be required to have at least two components which are the problem and the etiology of the problem; but ideally, nursing diagnoses should have all the elements of a complete and most beneficial nursing diagnosis, that is, the problem or diagnostic statement, a qualifier, the etiology of the healthcare need or concern and the defining characteristics of the healthcare need or concern as stated in the nursing diagnosis "Impaired spiritual comfort related to a terminal disease as evidenced by spiritual anxiety and distress."

Planning Phase of the Nursing Process

Planning is based on and follows the previously collected assessment data, the previous organization of the collected data, the careful and unbiased analysis of data, and the nursing diagnosis. Again, this planning should be in collaboration with the client, significant other(s), the registered nurse and other members of the interdisciplinary healthcare team.

The goal and the purpose of the planning phase of the Nursing Process are to insure that the client's and significant other's care is appropriate. All planning must be:

• Specific and appropriate to the identified needs of the client which can include an individual client, a family, family members, a group and a community or population
• Amenable to evaluation so that the effectiveness of the plan of care can be established
• Consistent the client's preferences, age specific and related needs, and cultural, ethnical, religious preferences, needs and wishes
• Updated and modified according to any new data and changes in the client's physical, psychological, social, religious/spiritual and cultural status and needs

This client care planning should be:

• Done in a timely manner
• An interdisciplinary process
• Collaboratively agreed to and participated in by the client and significant others.

A complete planning process consists of employing valid and analyzed assessment data to:

• Develop expected outcomes, or patient goals
• Establish priorities of care
• Decide upon implementation strategies, aspects of care and treatments that are consistent with and congruent with the client's needs, and other considerations such as evidence based practice

The planning can be categorized as initial planning, ongoing planning and discharge planning.

Initial planning, like the initial assessment of the client and their needs, is done upon admission to a hospital or entry into another care setting such as an outpatient facility. This planning should be completed as soon as possible after the first client contact.

Ongoing planning is planning that is done on a continuous and ongoing manner in order to insure that the plan of care accurately reflects the current client condition and their changing priorities of care.

Discharge planning, similar to initial planning, should also begin at the time of the nurse's first client contact. It cannot be delayed because lengths of stay are too short to wait to do discharge planning after the day of admission or the first client contact. Discharge planning typically reflects the ongoing care of the client along the continuum of care. For example, a discharge plan may include home health care or physical therapy in the client's home.

Setting and Establishing Client Priorities

As previously mentioned, the purpose of planning is to establish priorities of care, to determine what the patient's expected outcomes of care should be and to determine the interventions that should be given to the patient to achieve these expected outcomes as based on the patient's needs and the data that was collected during the assessment, the analyzing and nursing diagnosis phases of the Nursing Process.

Priorities of care are established using a number of methods and frameworks including the ABCs, Maslow's Hierarchy of Needs, and the ABCs combined with the MAAUAR method of priority setting.

The ABCs method of priority setting identifies the airway, breathing and cardiovascular status of the patient as the highest of all priorities in that sequential order.

Maslow's Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others, and the self-actualization needs in that order of priority from the highest priority to the lowest priority.

Lastly, the ABCs / MAAUAR method of priority setting places the ABCs, again, as the highest and greatest priorities which is then followed with the 2 nd and 3 rd priority level needs of the MAAUAR method of priority setting.

The 2 nd priority needs according to the MAAUAR method of priority setting after the ABCs include M-A-A-U-A-R which stands for:

• M ental status changes and alterations
• A cute pain
• A cute urinary elimination concerns
• U naddressed and untreated problems that require immediate priority attention
• A bnormal laboratory and other diagnostic data that are outside of normal limits and
• R isks including those relating to a healthcare problem like safety, skin breakdown, infection and other medical conditions

The 3 rd level priorities include all concerns and problems that are NOT covered under the 2 nd level priority needs and the ABCs. For example, increased levels of self care abilities and skills and enhanced knowledge of a medical condition are considered 2 nd level priority needs.

Expected outcomes of care are based on the data collected, data analysis, nursing diagnoses, and priorities of care.

• S = Specific
• M = Measurable
• A = Achievable
• R = Realistic
• T = Timeframe defined
• T = Trackable and measurable
• A = Agreed to by the client and significant other(s)

A complete and appropriate expected outcome of patient goals must have:

• A subject in the sentence . For example, the client, spouse, family member, group of people receiving the nursing care or the population of people who are receiving the nursing care MUST be the subject of the expected outcome statement. Client goals are client centered and not nurse centered. The nurse is NOT the subject of the expected outcome statement. All client goals must be in terms of the client and not the nurse or another healthcare provider.
• A verb that describes what the client will do, or say, or demonstrate in another manner.
• Conditions . Conditions specify the when, how, what, where and other specific performance criteria that clearly state what is expected in terms of the client's demonstration of the goal directed behavior or characteristic. For example, the conditions may state that the client will relate and/or discuss the components of the diabetic diet or they client may able to ambulate at least 3 times per day with a walker and the assistance of another.

An example of how to generate an appropriate expected outcome is to include "The client will…" or the "The wife will…" and then follow this statement with what exactly you can expect the patient or spouse to do. For example, "The client will ambulate at least 20 feet three times a day with a walker" is a good expected outcome. It is client centered ("The client will"), specific in terms of exactly what you expect the client to do, measurable in terms of feet and frequency, in a time frame, trackable, and presumably realistic and agreed to by the client.

Another example of a good, useful, complete expected outcome could be, "The patient will select appropriate attire each morning according to their planned activities and the environmental temperature." This expected outcome is in terms of the patient; it states "The patient will…" It is specific; it states "select appropriate attire" and "according to the planned activities and the environmental temperature"). It is within a time frame; it states "every morning.” And, it is also observable and measurable and able to be tracked each day over time.

Implementation Phase of the Nursing Process

Interventions are planned according to the assessment data, the analysis of the data, the nursing diagnoses, the priorities of care, and the expected outcomes of that care. Providing interventions to clients require that the registered nurse possesses and employs:

• Critical thinking skills
• Professional clinical judgment
• Problem solving skills
• Priority setting skills
• High quality and effective interpersonal skills
• High quality and competent psychomotor and technical skills

Nurses, including licensed practical nurses, perform independent and dependent nursing interventions. Independent nursing interventions are those things that nurses can provide to the patient without a doctor's order and dependent nursing interventions are those things that nurses can provide to the patient only with a doctor's order.

A dependent nursing intervention is the administration of medication which can only be done with a complete doctor's order; and independent nursing interventions include things like turning the patient, positioning the patient, and assisting with the patient's activities of daily living which can be done without a doctor's order.

Registered nurses render, and delegate, patient care and they document it during the implementation phase of the Nursing Process.

Care is given and implemented according to the plan of care, the particular healthcare facility's policies and procedures, the nurse's job description, their level of competency, and the scope of practice for the different members of the nursing team.

For example, some healthcare facilities allow licensed practical nurses to start and manage intravenous fluids, and others do not. Some registered nurses in a particular healthcare facility are permitted to change central venous line dressings, and others are not permitted to do so according to a particular healthcare facility's policies and procedures

Lastly, registered nurses must follow the scope of practice for their state. When a registered nurse does things that are not included in their legal state's scope of practice, they are practicing nursing outside of their scope of practice which can be punished with the suspension or revocation of the nurse's license to practice nursing.

• How is the Scope of Practice Determined for a Nurse?
• Scope of Practice vs Scope of Employment
• RN Scope of Practice

Registered nurses must deliver high quality, competent care to patients that is consistent with their healthcare facility's policies and procedures, their job description, their level of competency, and the scope of practice for the licensed practical nurse.

Evaluation Phase of the Nursing Process

The process of evaluation is done by collecting data related to the expected outcome, analyzing this data, comparing this analyzed data to the data collected prior to the current time and making a decision about whether or not the goals were completely, partially or not met at all.

Although the licensed practical nurse can collect evaluation data, it is the registered nurse who is accountable for the analysis of this data and the formal evaluation process as well as any modifications to the plan of care if these changes are indicated by this evaluation of the goal achievement or the lack thereof.

For example, the registered nurse monitors the patient's level of pain in about one hour after administering an ordered pain medication and then they will compare the patient's current level of pain the reported level of pain before the medication was administered. Did the patient's level of pain decrease, increase or remain the same?

Now, let's do a couple of sample questions for the nursing process and the roles of the registered nurse:

Your patient tells you that they are "very itchy". What kind of data is this?

• Historical data
• Subjective data
• Secondary data
• Objective data

The correct answer is B –subjective data

When a patient tells you that they are "very itchy", they are providing you with subjective data that cannot, like objective data, be observed and measured.

Historical data is old data and not current like this patient's statement. Lastly, secondary data comes from a source, like a spouse or a part of the medical record, rather than from the patient themselves.

Now let's try another question:

Which phase of the Nursing Process requires the consideration of the scope of practice for the registered nurse?

• Data collection

The correct answer is C – the implementation phase

The state scope of practice for the registered nurse is considered during the implementation phase of the Nursing Process. The scope of practice outlines what the registered nurse can and cannot do in terms of their implementation of patient care and the scope of practice for the licensed practical nurse specifies what the licensed practical nurse can and cannot do in terms of their implementation of patient care.

Data collection, participation in the planning process and evaluating the patient's responses to care are not associated with the nurse's legal scope of practice.

Now, let's try this one:

Which phase of the Nursing Process is NOT within the scope of practice for the licensed practical nurse?

• The data collection phase
• The data analysis phase
• The implementation phase
• The evaluation phase

The correct answer is B – the data analysis phase

The data analysis phase of the Nursing Process is not within the scope of practice for the licensed practical nurse. Data analysis is exclusively within the scope of practice for registered nurses. Data analysis requires the critical thinking and professional judgment skills that the registered nurse only is prepared to do.

Data collection, implementation and evaluation are within the scopes of practice for both the licensed practical nurse and the registered nurse, however, as previously discussed, there are some differences.

Now, let's do another question:

Which of the following is a complete and appropriate nursing diagnosis for a patient who was admitted with a high fever of unknown origin?

• The client will be free of complications such as dehydration.
• The nurse will monitor the patient's vital signs q 4 h.
• At risk for impaired fluid balance related to dehydration
• At risk for impaired fluid balance related to the febrile state

The correct answer is D – "At risk for impaired fluid balance related to the febrile state"

"At risk for impaired fluid balance related to the febrile state" is a complete and appropriate nursing diagnosis for a patient who is affected with a fever of unknown origin. This at risk nursing diagnosis consists a qualifier which is "impaired", a problem which is "fluid balance", and the etiology which is a "fever of unknown origin".

"The client will be free of complications such as dehydration" is an expected patient outcome and not a nursing diagnosis. "The nurse will monitor the patient's vital signs q4 h" is also a nursing intervention and "At risk for impaired fluid balance related to dehydration" is not appropriate for this patient because the etiology is the fever and not dehydration.

Caring is defined as the "Caring is defined as the "interaction of the nurse and client in an atmosphere of mutual respect and trust. In this col­laborative environment, the nurse provides encouragement, hope, support and compassion to help achieve desired outcomes".

Caring and compassion are universal elements of all aspects of nursing care in all settings for individuals, significant others, families, populations and communities.

Concepts of Caring and Related Concepts

Some of the concepts relating to caring and their definitions will now be discussed.

• Caring is "An intentional action that conveys physical and emotional security and genuine connectedness with another person or group of people" (Berman and Synder, 2012)
• Compassion is defined as one's feelings that you want to decrease and alleviate another's pain and suffering when you become aware of it.
• Empathy is "The ability to discriminate what the other person's world is like and to communicate to the other this understanding in a way that shows that the helper understands the client's feelings and the behavior and experience underlying these feelings" (Berman and Synder, 2012)
• Sympathy is defined as feelings of compassion that that prompt action but, unlike empathy, sympathy does not include having the same shared feelings.
• Altruism is the thoughtful and selfless actions that are taken when a person is motivated with compassion and the need to decrease and alleviate another's pain and suffering.

Theory of Human Caring

Jean Watson, who developed the Human Caring Theory, states that caring is the essence of nursing. According to Jean Watson, the ten nursing interventions that show and demonstrate genuine caring are:

• Initiating, developing and maintaining an environment and relationship with the client that is supportive of the client and the protective or corrective elements that are needed for the client's mental, physical, societal, and spiritual needs
• Facilitating the integration of existential, phenomenological and spiritual forces and influences into client care
• Initiating, developing and maintaining a helping and trusting relationship with the client and significant others
• The facilitation of transpersonal teaching and learning in the nurse-client relationship of caring
• Facilitating and promoting the expressions of positive and negative feelings
• Using effective problem-solving for decision-making
• Facilitating and assisting the client with the gratification of the clients' biophysical and psychosocial human needs
• Forming, developing and maintaining a humanistic altruistic value system when providing client care
• Instilling faith and hope into the client
• Recognizing and cultivating a sensitivity to one self and others

Now, here are some questions relating to care, an Integrated Process that will be integrated into the NCLEX-RN examination.

Which emotion entails sharing the same feelings as another?

The correct answer is B – Empathy

Empathy entails sharing the same feelings as another. Sympathy is a feeling of compassion that prompts action but sympathy does not include having the same shared feelings. Caring is "An intentional action that conveys physical and emotional security and genuine connectedness with another person or group of people" (Berman and Synder, 2012). Compassion is defined as one's feelings that you want to decrease and alleviate another's pain and suffering when you become aware of it.

Now, here is another practice question:

Whose theory describes caring?

• Jean Watson
• Dorothea Orem
• Madeline Leininger
• Martha Rogers

The correct answer is A – Jean Watson

Jean Watson developed the Human Caring Theory. Dorothea Orem developed the Self Care Theory; Madeline Leininger developed the Transcultural Nursing Theory and Martha Rogers developed the theory of Unitary Man.

Communication and documentation are defined as the verbal and nonverbal interactions between the nurse and the client, the client's significant others and other members of the health care team.

Events and activities associated with client care are recorded and documented in written and/or electronic records that demonstrate adher­ence to the standards of practice and accountability in the provision of care. This documentation is a form of written communication.

The primary purpose of communication and documentation is to convey a message from one person to another person or a group of people.

Communication

Communication is an interactive process that transmits some message, meaning, information, emotions, and/or beliefs to another person or a group of people. It establishes and maintains connectedness between and among human beings.

Communication can be written, verbal, nonverbal body language and in a graphic or pictorial way. An example of verbal communication is talking with a patient about the treatment that you will be giving them; an example of written communication is the documentation of medications administered so that others, including other nurses, know that any ordered medications have indeed been given according to the doctor's order; an example of nonverbal body language is tapping one's foot in the presence of a patient which conveys a message that the nurse is impatient; and graphic and pictorial communication is the primary purpose of art and art work. Art and music are universal ways of communicating a message or feeling without the use of words or writing. Nurses often use pictures and diagrams to communicate a message to a patient, particularly when they are non-English speaking and/or they are not able to verbally send and receive messages.

Components of Communication

Regardless of the type of communication, all communication consists of several essential components.

These components are the:

• Sender of the message
• The message itself
• The receiver of the message and
• The response or feedback that occurs.

The sender transmits and conveys the message to others; the receiver is the person who gets the message from the sender; the message is the information or emotion that is being conveyed or sent to another; and the feedback is the response of the receiver to the message.

For example, when the sender of the message gently touches the shoulder of a patient to convey caring and compassion, the receiver of the message, which is the patient, decodes this message as a feeling of caring and compassion after which the patient acknowledges these feelings verbally or nonverbally and then sends this message of acknowledgment back to the other person.

Notice that, in this example, the receiver of the message becomes the sender of the message when they respond back to the person who was the original sender of the message. This feedback allows the nurse to acknowledge that the message was received and to respond to the message.

Factors That Impact On and Affect Communication

Many factors impact on and affect communication. Some of these factors are beneficial to this dynamic, interactive process and others are barriers to effective communication. At all times, nurses must overcome barriers to communication when they exist. Communication with the patient and/or significant other is essential to nursing and the provision of patient care.

Factors that impact on communication include:

• Level of development and age
• Level of consciousness
• Emotional state and level of stress
• Language spoken
• The nature of the relationships between and among people involved in the communication process
• Individual values, beliefs and perceptions
• Past experiences
• The environment itself

The level of development and age impact on communication. For example, nurses communicate with neonates and infants with touch and a soft, soothing voice. Levels of consciousness and levels of awareness enhance the communication process when it is normal, but it hampers communication when the patient has a decreased level of consciousness and awareness.

High levels of stress and the presence of other stressors, such as pain, can be a barrier to effective communication.

Language and language skills, including vocabulary and reading skills, can also impede communication. Accommodations, like the use of a professional translator, may be necessary for some patients when they do not communicate in English.

The nature of the relationships between and among people involved in the communication process affects the communication process in many ways. For example, figures that are perceived as in a position of power and influence, like nurses and doctors, may impact on the openness of the patient who does not view themselves as an equal in the nurse-patient relationship.

Not only does culture impact on a person's values, beliefs, opinions and perspectives, culture also influences the person's use of terms and terminology as well as their perceptions of nonverbal messages. For example, some cultures view eye contact, touch and proxemics, which is the distance between people, differently than others who are outside of the culture. Some view touch as invasive and not caring, some view eye contact as a sign of honesty and others may view it as aggressive and hostile. Still more have different tolerances for various distances between them and the person they are communicating with. We will discuss these personal spaces and proxemics later.

Past experiences impact on the way many people communicate with others. For example, when a patient has been shunned in the past for expressing their true feelings of depression, for example, the person will be reluctant to discussing these feelings in the future.

Lastly, the physical environment and the tenor of the environment also impact on communication. For example, a calm, open, trusting environment at a comfortable temperature is conducive to communication and conversations; and an environment that is environmentally uncomfortable, not trusting and filled with judgments is not conducive to effective communication.

Verbal Communication

Verbal communication consists of words and sounds. When compared and contrasted to nonverbal communication, verbal communication is far more consciously controlled and often less ambiguous than nonverbal communication.

People simultaneously communicate with both verbal and nonverbal communication. At times, the messages conveyed with the verbal communication are consistent with the messages conveyed by nonverbal communication; however, this is often not the case. At times, the verbal and nonverbal messages do not match. For example, when a nurse stands at a patient's doorway with their arms crossed and their foot tapping on the floor while asking the patient why they seem to be upset, the verbal message conveys and communicates caring and compassion but the nonverbal foot tapping and crossed arms conveys and sends a message that the nurse is impatient, in a hurry and really not wanting the patient to tell the nurse why they are upset.

The tone of the voice, the speed or pace of the communication, the brevity, simplicity, the use of pauses, and the clarity of the message affect the communication and the communication process among and between people. For example, effective communication with a hostile patient should be done with a soft, calming voice that may deescalate the patient's level of hostility, and communicating with brief and clear messages often facilitates nurses' effective communication with confused and lethargic patients.

Pauses during a conversation, when not lengthy in duration, are helpful because it gives the sender and receiver of the verbal message time to think about the message and its meaning; however, lengthy pauses can be very uncomfortable at times.

Sounds are a form of verbal communication. When compared and contrasted to words, sounds are often more difficult to interpret. For example, a grunt may indicate a number of things including the presence of pain, restlessness and exasperation. For this reason, nurses should communicate with the patient to clarify the meaning of their sounds.

In summary, verbal communication must be modified according to the needs of the patient and their level of understanding within an open, honest and nonjudgmental and professional environment.

Nonverbal Communication

As previously mentioned, nonverbal communication is very often out of the conscious control of the sender of these nonverbal messages. Some refer to nonverbal facial cues as a "poker face."

Nonverbal communication like other forms of communication also transmits feelings and emotions but, unlike verbal communication, it does not communicate these feelings and emotions with words. Nonverbal communication is also not as clear and unambiguous as verbal communication is. It has to be interpreted by the receiver of the nonverbal communication message.

Nonverbal communication conveys a message with bodily movements, facial expressions, gestures, touch, the use of space and distance, eye movements and eye contact, bodily posture, and one's personal appearance.

For example, eye movements and eye contact can convey a number of emotions. Eye contact can convey honesty, caring and interest during communication and the lack of eye contact can convey that the person is dishonest, nervous and even with a low level of self-esteem. Also, communication at eye level with the patient conveys the message that the nurse and the patient are equals in the nurse-patient relationship.

Facial expressions convey a wide variety of emotions including sorrow, joy, boredom and pain; a lack of facial expression, referred to as a flat affect, communicates a lack of interest and/or the presence of a psychological problem.

Proxemics and Territoriality

Proxemics is the use of personal spaces during the communication process. Although individuals and some cultures may differ in terms of their use and tolerance of different personal spaces, most Americans have these spatial distances:

• The Intimate Zone : This zone ranges from direct bodily contact and touching to a distance of about 1 ½ feet away from the body's surface.
• The Personal Zone : This zone begins at 1 ½ feet away from the body's surface and it continues to about 4 feet away from the body.
• The Social Zone : The social zone extends from about 4 feet away from the body to 12 feet from the person.
• The Public Zone : The public zone is defined as 12 or more feet from the person.

The intimate zone is typically reserved for intimate partners; however, the intimate zone is often invaded by nurses and other healthcare providers as they care for patients. For example, the intimate zone is invaded when a nurse gives a caring touch to a patient, when a urinary catheter is inserted, when perineal care and bathing are provided and when the patient is turned and positioned in bed.

Many patients become overwhelmed and uncomfortable when their intimate zone and/or their personal zone are invaded, therefore, nurses and other members of the healthcare team must always explain procedures to the patient before rendering care and they must also provide the patient with as much personal privacy as possible during the provision of care.

Territoriality is the connection of possessions and things with a person. Feelings of territoriality and the need to protect one's territory is part of human nature. People protect their territories in their home and in healthcare facilities. For example, a patient may feel that their room in the hospital is their territory and they may feel they need to protect it. Nurses, therefore, must knock on the door and get permission to enter from the patient and they should also ask the patent for permission before moving and rearranging things in the bedside area.

Therapeutic Relationship and Therapeutic Communication

The therapeutic nurse-patient relationship begins with the establishment of trust after which this relationship matures to an effective one that employs proper therapeutic communication techniques.

Some of these therapeutic communication techniques are:

• Attentive, Active Listening : Although many do not immediately recognize the fact that listening is an essential part of communication, it is. Attentive listening is far more than hearing; attentive listening involves active listening and it is not a passive activity.
• Silence : Like listening, many do not realize that silence is a useful part of communication. Silence allows the sender and the receiver of the conveyed message to think about the received message and to contemplate the best response or feedback to the other person relating to the message. When silence is prolonged, however, it may make some feel uncomfortable and/or that there is no interest in the conversation by the other.
• Reflection : This form of therapeutic communication mirrors, or reflects, the patient's feelings, not words, back to the patient's so that these feelings can be further explored and expressed by the patient. For example, when the nurse states, "You seem very stressed today", the patient will be likely to tell the nurse why they are upset.
• Focusing : This therapeutic communication technique allows the patient to remain focused on the subject at hand rather than becoming distracted and disorganized in terms of the conversation. For example, the nurse may say, "Mr. Jones, we will talk about the diabetic diet in a little while, but now let's discuss you blood glucose results over the last month".
• Paraphrasing and Restating : Restating and paraphrasing allows the nurse to acknowledge that they have a good understanding of what the patient has said and meant in their sent message. An example of paraphrasing and restating is, "I heard you state that you are going to agree to the surgery for next week."
• Clarification of Received Messages : Received messages are always clarified and validated with patients to insure that the nurse has received and interpreted the complete and correct message without any errors or false assumptions.Nurses can clarify patient messages by asking the client a question like, "Am I correct that you told me that you plan on having the surgery done next week?"
• Providing Leads to the Patient : Providing the patient with a lead facilitates the patient's open expression of feelings, concerns and messages. Providing a lead like, "Tell me a little bit more about your concerns relating to your surgery next week" will promote and facilitate the patient's communication with the nurse.
• Summarizing : Summarizing is highly useful to sum up the main points of the nurse-client interactive discussion and also to further validate that messages sent and received were interpreted correctly. For example, the nurse may state, "During this conversation, we talked about your blood glucose readings and specific ways, including dietary choices, that you can lower your blood glucose levels."

Ineffective Communication

Some of the things that can impede effective, therapeutic communication include making judgments, stereotyping and assuming that all people in one group or another has the same opinions, beliefs or practices, changing the subject or topic of conversation, challenging, probing, and being defensive during communication.

Overcoming Barriers to Effective Communication

Nurses are responsible for effective communication with patients. In order to fulfill this responsibility, nurses must immediately identify any barriers to communication and then overcome these barriers with effective strategies.

For example, the nurse will use simple terms and make discussions brief when the patient is in pain or confused; the nurse will modify their terminology and vocabulary when they are communicating with a young child for example; and the nurse will also use therapeutic touch when a patient is upset or sorrowful.

Documentation

Like verbal and nonverbal communication, written documentation is used to transmit and convey messages. In fact, the primary purpose of documentation is communication. Other purposes of documentation include meeting the legal mandates relating to Medicare's Conditions of Participation, using documentation for reimbursement from third party payers like health insurance companies, and also to meet the regulatory requirements of the states and to fulfill the recommendations and standards put forth by other regulatory bodies such as the state departments of health and Joint Commission on the Accreditation of Healthcare Organizations.

Medical Records and Documentation

Documentation must be complete, timely, accurate, objective and factual.

Some forms of documentation in the healthcare environment are the clients' medical records, care plans, employee schedules and time cards, policies and procedures, minutes of meetings, interoffice letters and messages, and e mails.

All medical records and all parts of it are legal documents. This legal nature of documentation applies to hard copy and electronic versions of the medical record.

In order to be effective, documentation must be complete, timely, accurate and professional. It must reflect all patient care, data and information; it must be done in a timely manner and according to the policies and procedures of the healthcare facility and other legal or regulatory requirements; it must be without errors and it also must be professional, legible, clear, understandable, and without any ambiguity.

Complete, timely, accurate and professional documentation prevents errors of commission and omission, it avoids unnecessary delays in treatment and care, and it facilitates the highest possible quality of care for the patient.

Most documentation errors are errors of omission. The nurse, or another healthcare provider, neglects to, forgets to, and/or simply fails to document something that should have been documented.

Errors of commission can also occur. For example, the certified nursing assistant or nurse who records incorrect vital signs in the patient's medical record has made an error of commission relating to documentation. All documentation errors have the potential to lead to serious and severe patient effects including death.

Approved and Acceptable Abbreviations and Terminology

A multitude of abbreviations can be differently interpreted among healthcare providers, therefore, the Joint Commission on the Accreditation of Healthcare Organizations and common sense mandates that only accepted and approved abbreviations and terminology are used for documentation. The use of these risky abbreviations jeopardizes client safety and the quality of care that they are given. For example, the abbreviation "MS" is NOT an approved abbreviation because "MS" can be interpreted as multiple sclerosis, morphine sulfate and magnesium sulfate.

All healthcare facilities are required to have a formalized list of unacceptable abbreviations that cannot be used because they are problematic and can lead to errors and confusion.

Some of the abbreviations that are no longer used include:

• IU for international unit
• for once daily
• qod, for every other day
• A trailing zero like 9.20 milligrams
• The lack of leading zero like .9

Legal Aspects of Documentation and Documents

Some of the legal aspects of documentation include the legal prohibitions against altering a record, obliterating entries in the medical record, and falsifying documentation.

Medical documents are protected as confidential records; and sharing or accessing patient information is prohibited except when this sharing and accessing is necessary to provide care to the patient.

Types of Medical Records and Documentation

All types of medical records and documentation systems have advantages and disadvantages. Healthcare facilities select the types of medical records and documentation systems that they use.

The most commonly employed types of medical records are:

• Source Oriented Medical Record

Focused Charting

Charting by exception, problem oriented medical record.

• Case Management & Critical Pathways

The Source Oriented Medical Record

The source oriented medical record is the oldest kind of medical record documentation. The source oriented medical record is typically kept in a binder or a metal flip chart with dividers that are labeled with the contents of each section. For example, nursing, laboratory, physical therapy and medical doctors each have a separate section in the source oriented medical record for their own documentation.

This discipline specific chart typically includes flow sheets, vital sign graphic charts, progress notes and other forms of documentation such as the medication record, doctors' order sheets, the medical history and physical, the nursing admission assessment, and a standardized patient teaching form or record.

Some of the advantages of the source oriented medical record include the fact that it highly familiar to healthcare providers, it is relatively simple to use, and the progress notes are typically free flow narrative notes that do not require a special format like other systems, such as the problem oriented medical record.

Some of the disadvantages of the source oriented medical record include the fact that they are not multidisciplinary in nature and the fact that the patient information is scattered all over the medical record.

Focused charting is less commonly encountered than other documentation systems. Focused charting makes patient related issues, like the patient's problems, the patient's strengths, the patient's nursing diagnosis and changes in the patient's condition, the focus of the medical record.

The progress note for focus charting is done on a three columned form that includes the date and time of the entry, the focus or patient related issue and the progress note that is done in the DAR format. DAR stands for Data, Action and Response as shown below.

Data is assessment data, action is what was done to solve the patient problem or concern, and the response reflects the evaluation of the patient after an intervention in terms of their negative or possible responses to the intervention.

An advantage of focus charting includes the fact that it is relatively simple to use but its disadvantages are similar to those of the source oriented medical record, that is, focus charting is not multidisciplinary in nature and the patient information is scattered all over the medical record.

Charting by exception is based on the principle that only abnormal and significant things have to be recorded and documented. This method is rarely used because it has some serious disadvantages.

The charting by exception method employs flow sheets of all types, references to established standards of nursing care, and a narrative nursing progress note which only includes significant and/or abnormal data and information.

An advantage of this method is that it significantly decreases the length of the progress notes because only abnormal and significant data and information are documented.

The perils and pitfalls of charting by exception, however, can potentially jeopardize patients because, with this system, it is assumed that ALL exceptions have been charted and documented when, in reality, many nurses and other healthcare providers simply forget to chart and document as they should. When documentation is not done, a person can assume that, for example, the patient's vital signs were normal when in fact they are not.

The problem oriented medical record is very distinct from the source oriented medical record and other documentation systems.

The problem oriented medical record is multidisciplinary and, instead of patient information being spread throughout the medical record for each discipline like nursing and physical therapy, the patient information and data are organized and clustered according to the patient's problems in one part of the client's medical record.

All members of the healthcare team, including the doctors, nurses, and others, collaboratively develop, maintain and compile a complete list of patient problems. Each of the disciplines in the multidisciplinary team then provide and document the care and services that they provide in reference to one or more of these documented patient problems. The established and ongoing problem list for the client is typically found in the front of the client's medical record for easy access and updating as the client's condition changes.

This method of documentation consists of a patient data base, a formalized list of problems that is typically placed in the front of the patient's medical record for rapid reference, a plan of care and uniquely done patient progress notes that are also multidisciplinary.

The data base section includes assessment data like the medical history and physical, the nursing assessment and other information.

The problem list, as based on the patient's current assessments and condition, includes bio-psycho-social, cultural, spiritual and educational needs. Medical doctors typically write problems using the patient's medical diagnosis such as "COPD" and nurses typically record patient problems using a nursing diagnosis such as "At risk for impaired skin integrity related to immobility".

The plan of care is also generated by all the disciplines in the healthcare team and it, too, is directly aligned with the established problem list. As with all other documentation systems, ongoing assessments, modifications of the problem list and changes in the plan of care are done in an ongoing manner according to the changing status and needs of the patient.

The progress notes for the problem oriented medical record are also multidisciplinary and, instead of free flowing narrative progress note, these progress notes are highly structured, goal directed, and organized according to the patient problems. For example, if a patient problem is a cerebrovascular accident, the progress notes are labeled with the specific problem number and label.

The format of the progress notes is one of the following as decided upon by the particular healthcare agency. It can be:

A SOAP progress note for Problem # 1: At risk for impaired skin integrity related to immobility may appear like this:

• S – Subjective data: The patient states that they "are turning themselves in bed"
• O – Objective data: The patient's skin is dry an intact
• A – Assessment: Intact skin
• P – Planning: Encourage out of bed activity and continue to monitor the condition of the skin

The SOAPIE progress note for Problem # 2: COPD can be composed like this:

• S – Subjective data: "I am breathing better after my treatment"
• O – Objective data: Decreased pallor and cyanosis
• A – Assessment: Improved arterial blood gases
• P – Planning: Continue the plan of care
• I – Interventions: Monitor the client and administer respiratory medications and treatments as ordered
• E – Evaluation: Respiratory medications and treatments are effective

The SOAPIER progress note for Problem # 2: COPD can be composed like this:

• S  – Subjective data: "I am breathing better after my treatment"
• O – Objective data: Decreased pallor and cyanosis
• I – Interventions: Monitor the client and administer respiratory medications and treatments
• R – Revisions: Encourage increased activity

The advantages of the problem oriented medical record are that it promotes multidisciplinary collaboration among the various disciplines; it is organized in a method that facilitates ready access to the patient's current problems and it allows members of the healthcare team to track and review the patient's progress over time according to their documented healthcare problems and concerns.

The disadvantages of the problem oriented medical record include the facts that this method is unfamiliar to nurses and other healthcare team members and it is more difficult than other methods in terms of the structured format of the progress notes.

Problem, Intervention and Evaluation (PIE) Progress Notes

The PIE method for documenting progress notes can be used in the problem oriented medical record or with any other style of medical record.

An example of PIE using a problem like postoperative pain is below:

• P : Problem: Pain related to abdominal surgery
• I: Interventions: Monitor the patient's level of pain and administer analgesics for pain as ordered prn
• E : Evaluation: Pain level has decreased from 8 to 4 after analgesic medication

Assessment, Problem, Intervention and Evaluation (APIE) Progress Notes

APIE is an expansion of the PIE method but it adds assessment data.

• A : Assessment: The patient reports an 8 level of pain and the patient is guarding the incisional site.
• I : Interventions: Monitor the patient's level of pain and administer analgesics for pain as ordered prn

Case Management and Critical Pathways

Case management and the use of critical pathways is perhaps the newest of the documentation systems.

Case management and critical pathways are based on the premise that most patients with a specific medical diagnosis, healthcare problem, illness, and/or nursing diagnosis are more similar in terms of their anticipated treatments than they are different.

Briefly stated, critical pathways are pre planned plans of care that are generated with the efforts of the entire multidisciplinary team, as appropriate according to the patients' diagnoses, and include interventions, time frames and expected outcomes.

The time frames vary according to the patient's level of acuity. For example, patients in the special intensive care unit have more frequent monitoring and care than a resident in a long term care facility and a stable patient in a medical/surgical unit after surgery without any complications. The time frames for the client in the emergency and special care intensive care areas may be as brief as every 15 minutes; the time frames for the client in a long term care facility may be as long as every month; and the time frames for the stable patient in a medical/surgical unit after surgery without any complications may be every 4 hours or every shift, for example.

A variance occurs and is documented whenever the patient's established critical pathway is not followed. Variances can include patent related, provider related and system related variances. For example, if a critical pathway is not followed because the current patient's condition does not permit a particular intervention, which is a client or patient related variance, or a provider fails to draw a preplanned laboratory test, which is a provider related variance, or the system fails in terms of processing and/or reporting the results of a radiological study, which is a system related variance, a variance has occurred. All variances are documented using this critical pathway method of documentation and care planning.

Not only are variances and their documentation significant, crucial and critical to the quality of patient care, they are useful and beneficial in terms of providing data that can be used in process improvement and performance improvement studies. For example, the analysis of variances over time may suggest patterns and trends that should be addressed in terms of increasing the timeliness, appropriateness and completeness of care or client assessments.

A sample critical pathway is shown below:

Guidelines for Documentation

In addition to the legal aspects of documentation that were previously mentioned, other guidelines for documentation include the use of permanent ink, the use of only accepted terms and abbreviations, legible writing, accurate spelling, proper grammar, accurate dating and time of the entry, the signature and title of the person who documented the entry, and a professional tone.

If an error in documentation occurs, a thin line that does NOT obliterate the entry is drawn through the erroneous entry, the notation "Error" is written above the entry and the nurse signs this notation with their name and title.

Under no circumstances should any pre charting or charting and documenting for others be done.

Now, here are some sample questions for the Communication and Documentation section:

Which communication technique is the vaguest of all?

The correct answer is C – a groan

Sounds like a groan are the vaguest of all of the above communication techniques. It can have many meanings. Touch has one meaning; it conveys caring. Silence can indicate thought or it can simply be a pause in the conversation. Lastly, a smile is a universal sign of happiness or fondness.

Now, let's do another one.

Place the letters of a problem oriented medical record progress note in correct sequential order:

R O S P A I E

SOAPIER is the correct sequential order for the problem oriented medical record.

Teaching and Learning is defined as the "facilitation of the acquisition of knowledge, skills and attitudes promoting a change in behavior."

Basic Terms and Terminology Relating to Teaching and Learning

Some of the basic terms and terminology relating to the teaching and learning process that you should know will now be discussed.

• The assessment of learning needs is the collection and analysis of data and information that reveals that the patient has an actual or potential learning need. Registered nurses analyze this data and information; licensed practical nurses can contribute to the collection of this data and information, but they do not analyze the data.
• A learning need, simply stated, is defined as the gap or a discrepancy between what the patient should know or be able to do and what they actually do know and are able to do. For example, a learning need nursing diagnosis for a newly diagnosed diabetic patient may be a "Knowledge deficit relating to the role of exercise in the management of diabetes" when the assessment of learning needs indicates that this gap in knowledge about the role exercise in terms of diabetes management.
• Andragogy is adult learning and adult learning principles.
• Pedagogy is childhood learning and childhood learning principles.
• The domains of learning are the three types or domains of learning. The three domains of learning are the affective domain of learning, the cognitive domain of learning and the psychomotor domain of learning.
• The affective domain of learning involves values, beliefs, feelings, interests and other social and emotional elements.
• The psychomotor domain of learning entails "hands on skills" like using the correct procedure for the self administration of insulin and using the correct procedure for monitoring blood glucose levels.
• The cognitive domain of learning is the knowledge and thinking domain. For example, a patient teaching plan for a newly diagnosed diabetic client will contain information about diet, exercise and their diabetic medications.
• Teaching is a planned, dynamic, systematic process like the nursing process. Teaching consists of the assessment of learning needs, the generation of a learning need nursing diagnosis, the generation of educational patient goals or expected outcomes, the planning of educational activities, implementation and evaluation. It is an active process that imparts some knowledge, skill or ability to a person with a learning need.
• Learning is the acquisition of new knowledge, skills or abilities. When learning occurs, a change in the patient's behavior and/or attitudes should occur.

Teaching Learning Process

The teaching/learning process is a planned, dynamic, systematic process like the nursing process that includes:

• The assessment of the patient's learning needs
• The organization of assessment data
• The analysis of the educational related data
• The generation of a nursing diagnosis based on the learning need
• The planning of an appropriate educational activity
• The implementation of the teaching/learning plan
• The evaluation of the education in terms of the client and their increased knowledge and/or a change in behavior

Assessing Learning Needs and Other Factors

During the assessment and data collection phase of the teaching/learning process, nurses collect information about the patient's learning needs, their strengths and weaknesses in terms of learning, their learning styles and preferences, their level of motivation, and other factors including other patient characteristics and potential barriers that may negatively impact on the education and the effectiveness of the education.

Learning styles, other patient characteristics and barriers to education will be fully discussed later in this section.

Analyzing Learning Needs Data

After data is collected, the registered nurse organizes and analyzes this data in the same manner that the registered nurse analyzes data during the nursing process using the professional judgment and the critical thinking skills of the registered nurse.

Learning Need Nursing Diagnoses

The registered nurse then generates a learning need nursing diagnosis such as:

• A "knowledge deficit relating to the performance of active range of motion exercises" which is within the psychomotor domain of learning and "At risk for a performance deficit relating to the self administration of insulin secondary to impaired fine motor skills" which is also within the psychomotor domain of learning
• A "lack of knowledge about antihypertensive medications and their actions" which is within the cognitive domain of learning
• A "lack of motivation relating to the performance of self care activities" which is within the affective domain of learning

Planning Educational Activities: Expected Outcomes and Selecting Teaching Methods

Registered nurses often collaborate with other members of the healthcare team to plan educational activities for individual patients, their significant others and groups of patients who share a common educational need. For example, the registered nursing may collaborate with a dietician to plan an educational activity for an individual client and their significant others in terms of the dietary management of high cholesterol or triglycerides, or the registered nursing may collaborate with a pharmacist or a physical therapist to plan a series of educational activities for a large or small group of newly diagnosed diabetic clients who have shared and common educational needs relating to diabetic medications and the role of exercise in terms of diabetes management, respectively.

During the planning stage, the nurse generates learning objectives or expected outcomes for the patient or the group of patients. Like the nursing process and its expected outcomes, or goals, educational related expected outcomes are also S-M-A-R-T-T-A.

Expected outcomes are also:

• Time framed
• Agreed to by the patient.

Learning objectives, or outcomes, are in terms of what the person will know, or do, after the planned education is given. They are also written according to the domain of learning that is being taught. For example, a psychomotor domain learning outcome could be, "The patient will change their dressing using medical aseptic technique" and a cognitive domain learning outcome could be, "The patient will list the foods that are not permitted with a soft diet."

The format of these documented expected outcomes relating to education is "The patient will…" followed by a measurable and observable verb that is consistent with the domain of learning. For example, some expected outcomes for the cognitive domain of learning are "The patient will describe, list, define, summarize and discuss…" Some expected outcomes for the psychomotor domain of learning are "The patient will perform and demonstrate the proper procedure for…" and "the patient will select heart healthy foods". Similarly, expected outcomes for the affective domain of learning could include "The patient will value …" and "The patient will demonstrate a belief that…"

Teaching strategies must be selected based on the domain of learning that is being taught. For example, lecture and discussion are appropriate strategies for the cognitive domain; demonstration, return demonstration and practice are appropriate strategies for the psychomotor domain of learning; and role playing as well as value clarification exercises are appropriate strategies and methodologies for the affective domain of learning.

Other strategies that can be used for the cognitive and psychomotor domains of learning are:

• Online classes and information, reading material, videos, posters and pictures for the cognitive domain of learning.
• A video showing the procedure, live demonstration, simulated practice and the use of a medical model for the psychomotor domain of learning.

The content and information that is planned for the educational activity should be sequenced from the known to the unknown, from the simple to the complex, and from the least threatening to the most threatening. Additionally, psychomotor skills should be taught going step by step through the procedure with the learner(s) beginning with step one and then proceeding to the last step of the skill or procedure.

Patient and family teaching activities are planned for adults using androgogy. Pedagogy is childhood learning; androgogy, is adult learning.

Unlike pedagogy, adult learning must have immediate usefulness in terms of solving problems; it involves active learner involvement and participation; and the curriculum and content are based on the learner's problems, needs and desires and not the state or federal government like pedagogy does.

Implementing the Teaching Plan

When time permits, psychomotor skills are best taught with short teaching sessions for each step of the procedure after which time the patient can practice what they have just learned before they are taught the next step.

Many clients have a short attention span and short term memory that may interfere with the learning process; therefore, the teaching sessions should be brief and modified, as based on the individual’s need.

Evaluating the Outcomes of Education

The two kinds of evaluation that are used for education are formative evaluation and summative evaluation.

Formative evaluation is determining how effective the education is at the same time the educational activity is being conducted; and summative evaluation determines how effective the education was after the educational activity has ended.

Formative evaluation allows us to adjust or modify the teaching and/or to overcome any barriers to learning during the teaching session so the teaching can be made more effective when necessary. For example, when a patient does not appear to understand what you are teaching, you must adjust and modify the teaching with strategies such as using simpler language, using pictures, and clarifying the content as often as necessary during the teaching session to increase the level of understanding.

Summative evaluation allows us to determine if the education that was provided has met or exceeded or not at all met the patient's expected outcomes in terms of the knowledge, skills and/or abilities that was taught. Did the education close the gap between what should be known or done and what actually is known or done?

Evaluation methods also vary according to each of the domains of learning. Questioning and giving a test are ways that cognitive domain learning can be evaluated. Having the patient return demonstrate a "hands on" or psychomotor procedure or skill is the best way to evaluate psychomotor domain learning; and, the affective domain can be evaluated by observing the patient's changes in terms of their attitudes, beliefs or values, for example.

Learner Characteristics and Preferences

Learners, like all other human beings, are different in terms of the characteristics and preferences. Learners vary in terms of their cognitive abilities and their fine and gross motor skills which can impact on psychomotor skills acquisition; they also differ in terms of their learning styles and preferences, and they also vary in terms of other characteristics that can impact on the teaching and learning processes.

In terms of the learners' characteristic learning styles and preferences are the following:

• Visual Learners : Visual learners learn best and have a preference when they are able to see things like an educational video, a live teacher demonstration, medical models, pictures and diagrams.
• Verbal Learners : Verbal learners, on the other hand, learn best and have a preference when they are able to hear the teachers' spoken words. These spoken words can be delivered to the learner in a live presentation or with a taped presentation.
• Tactile Learners : Tactile learners learn best and have a preference when they are able to learn by doing rather than seeing or hearing. They learn best with "hands on" experiences and the opportunity to manipulate, practice, and experiment with things.
• Active Learners : These learners prefer to learn when they actively engaging with others, including the teacher, such as when they are discussing things with others and they are working on a small group project.
• Reflective Learners : Unlike active learners, reflective learners tend to prefer working alone and thinking alone in solitude rather than interacting with others and working on small group projects.
• Sequential Learners : These learners learn best when content is orderly, logical, and orderly and presented in a step by step manner. Sequential learners will then follow these logical and orderly steps to learn the content or skill and then to solve problems related to the content or skill that was taught.
• Global Learners : Global learners, unlike sequential learners, do best when they themselves, rather than the teachers, are able to organize the content themselves during the learning process.
• Sensing Learners : These learners prefer concrete and practical "real world" learning to solve a problem rather than abstraction and information that they cannot readily use.

Whenever possible, the nurse should use a variety of methods that meet most learner preferences when a group presentation is being given and they should employ the individual's learning preference strategies when one-to-one individual teaching activities are given.

Barriers Related to Learning

Some of the potential barriers to learning and possible ways to overcome these barriers will be discussed now:

English Language Barriers

Teaching and communicating with patients who do not have English as their primary language pose challenges in terms of teaching. The patient may not understand what is being taught.

Some of the things that you can do to overcome this barrier is to use pictures, to provide written information in the patient's native language, to get the help of a professional translator, to use simple terms and words without any medical jargon when the person is limited in terms of the English language, to speak slowly and clearly, and to clarify and restate whenever necessary.

A Low Level of Literacy

Individuals vary in terms of their levels of literacy and ability to read and understand material. For example, some patients can read and understand complex material with ease and others may have poor literacy skills that cause them to only understand material that is written at or below 6 th grade reading level.

The nurse must determine the patient's literacy level and then provide them with material and information that they are able to read and fully understand.

Poor Health Literacy

Many people across our nation are, unfortunately, not health literate. Health literacy is the ability of the person to make knowledgeable and appropriate healthcare decisions that are based on the particular person's sufficient level of understanding of the particular healthcare concern or need that they are making a decision about.

Registered nurses must assess clients' level of health literacy and provide the understandable patient education that is necessary to insure that the client is making a knowledgeable decision about their care or treatments.

For example, nurses and other healthcare providers must use simple, understandable terms and terminology as well as alternative aids such as pictures or a medical model, to enhance learning. All medical jargon and complex explanations should be avoided.

The Lack of Motivation and Readiness for Learning

Patients have to be motivated and ready to learn before any learning can occur.

Nurses can motivate and encourage patients and significant others to learn by convincing them that the education will help them to solve their healthcare problems and concerns and also empower them in terms of making knowledgeable decisions relating to their health and health care.

The Presence of Stress and Pain

The presence of pain impedes learning. The nurse should consider using interventions, including pain medications, to reduce the pain prior to the teaching episode.

Mild stress is a motivator, but high levels of stress hamper effective learning. Again, the nurse should consider stress management strategies to reduce high levels of stress prior to the learning.

Age Specific Variables

The age and developmental level of patients also impacts on the teaching and learning processes.

Some examples of teaching modifications that are based on age and the learner's developmental level include simple concrete and brief explanations for the toddler, simple and brief explanations for the pre-school child, the encouragement of questions and more detailed explanations for the school age child, and adult like teaching for the adolescent.

Health Beliefs Including Spiritual, Cultural and Self Efficacy Beliefs

Patients who value health, health promotion and wellness will be most likely to be motivated to learn when compared and contrasted to other patients who do not value these same things.

Some of these beliefs can be spiritual, cultural and intrinsic in terms of their origin. For example, some believe that "medicine men" perform the role of a healthcare provider, rather than a medical doctor; others may have a cultural belief that immunizations are dangerous and not necessary; and still more may have an intrinsic belief that they are not able to do anything to solve their health related problem. It is all out of the control. These patients lack feelings of self efficacy and empowerment.

Nurses can overcome these barriers to learning by instilling new and different values and beliefs into the teaching session at the same time that any existing values and beliefs are incorporated into the teaching as much as possible.

Cognitive, Psychological and Emotional Challenges

Nurses have to accommodate for any actual or potential cognitive, sensory, psychological and emotional barriers to learning.

For example, cognitive limitations can be overcome with slow, brief, simple and understandable explanations. Psychological and emotional barriers can be decreased when the nurse-patient relationship is built on trust, respect, caring, and compassion.

Physical and Functional Limitations

Sensory barriers, like impaired vision and hearing, can be overcome with louder discussions with clients affected with a hearing loss, large print materials and Braille materials for the visually impaired, and the use of sensory assistive devices like glasses, magnifiers, and hearing aids.

Accommodations and modification must also be done when the learner has a functional limitation that can potentially hamper learning. For example, a patient with poor fine motor abilities and coordination may need an assistive device that accommodates for this.

Now it is time for you to be challenged with two sample questions relating to the teaching and learning processes:

"The ultimate purpose of teaching and learning is for the patient to…”:

• Understand about their healthcare problem.
• Be knowledgeable.
• Be enlightened.
• Change behavior.

The correct answer is D- To change behavior

The ultimate purpose of teaching and learning is for the patient to change behaviors that can correct their healthcare problems and needs. Understanding, being knowledgably and enlightenment are needed for a change of behavior but it is a change in behavior is the ultimate goal of teaching and learning.

Now, here is another one:

What strategy would you use to teach a patient how to check their own blood pressure?

• Demonstration
• Reading material
• Affective learning

The correct answer is B- Demonstration

You would use demonstration to teach a patient how to check their own blood pressure because this is a psychomotor skill. Psychomotor skills are best taught with demonstration.

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What is the Nursing Process?

Characteristics of the nursing process, history of the nursing process.

Understanding the nursing process is key to providing quality care to your patients. The nursing process is a cyclical process used to assess, diagnose, and care for patients as a nurse. It includes 5 progressive steps often referred to with the acronym:

• Planning/outcomes
• Implementation

In this article, we’ll discuss each step of the nursing process in detail and include some examples of how this process might look in your practice. 

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The nursing process is a patient-centered, systematic, evidence-based approach to delivering high-quality nursing care. It consists of five steps: assessment , diagnosis , outcomes/planning, implementation, and evaluation.

The Nursing Process (ADPIE)

1. Assessment

To begin the nursing process, assessment involves collecting information about the patient and their health. This information is used to identify any problems, or potential problems, that may need to be addressed while you’re caring for a patient. 

Example: If you’re admitting an older patient who is falling and getting injured at home, you’ll want to do a thorough physical and mental health assessment, including a medical history to try and determine why this is happening. 

Some important things you’ll want to find out are:

• What medications and over-the-counter products is the patient taking
• History of alcohol and recreational drug use
• Where the person lives and the layout of their home, including scatter rugs they may be tripping over: clutter, pets, stairs, slippery tubs they’re climbing into or out of, fluid or food spills on floors, lighting, mobility aids they use, etc.

2. Diagnosis

The Nursing Diagnosis is the second step in the nursing process and involves identifying real or potential health problems for a patient based on the information you gathered during the assessment. 

Example: Using the falls patient example above, you may identify from your assessment that the patient is falling because they’re tripping on things in their environment that they don’t see, like their pet cat lying on the floor and loose scatter rugs. 

Based on this, you might form a diagnosis such as “Falls related to poor vision, cluttered environment, unsteady gait, Lt. hip pain due to previous fall.”

3. Outcomes/Planning

Planning or Outcomes is the third step in the nursing process. This step involves developing a nursing care plan that includes goals and strategies to address the problems identified during the assessment and diagnosis steps. 

Example: Continuing with the example above, you will likely recommend that the patient keep their environment,

• Free of scatter rugs
• Check to ensure the cat is not underfoot before they mobilize
• Suggest the patient use a walker for support when mobilizing
• Recommending that the patient schedule an eye exam to get their vision checked if they have not had one in the last year or two would also be a good idea or if they’ve noticed any changes in their vision lately.

4. Implementation

As the fourth step of the nursing process, implementation involves putting the plan of care into action. 

Example In the above example, this would include: 

• Making sure the patient’s environment is free of clutter and tripping hazards while in the hospital or a skilled nursing facility.
• Teaching the patient to wear proper footwear before mobilizing.
• Assisting the patient with mobility as needed, including putting proper footwear on the patient if needed.
• Speaking to the patient and family about removing scatter rugs from the patient’s home, scheduling an eye exam, and ensuring proper footwear is worn for mobilizing at home.
• Discussing with the patient and family about getting the patient a walker to assist with mobility on discharge and providing one while the patient is admitted.

5. Evaluation

The last step of the nursing process is evaluation , which involves determining whether or not the goals of care have been met. 

Example Here you would look back at the patient’s medical record to see if the patient has had any further falls since implementing the preventative actions above. 

If so, you would repeat the nursing process over and reassess why this is still happening and plan new actions to prevent future falls.

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The nursing process is also characterized by the following elements. 

1. Dynamic and Cyclic

The nursing process is an evolving process that continues throughout a patient’s admission or illness and ends when the problems identified by the nurse are no longer an issue.

2. Patient-Centered and Goal-Directed

The entire nursing process is sensitive to and responsive to the patient's needs, preferences, and values. As nurses, we need to act as patient advocates and protect the patient’s right to make informed decisions while involving the patient in goal setting and attainment.

3. Collaborative and Interpersonal

This describes the level of interaction that may be required between nurses, patients, families and supports, and the interprofessional healthcare team. These aspects of the nursing process require mutual respect, cooperation, clear communication, and decision-making that is shared between all parties involved.

4. Universally Applicable

As a widely and globally accepted standard in nursing practice, the nursing process follows the same steps, regardless of where a nurse works. 

5. Systematic and Scientific

The nursing process is also an objective and predictable process for planning, conducting, and evaluating patient care that is based on a large body of scientific evidence found in peer-reviewed nursing research.

6. Requires Critical Thinking

Most importantly, it’s essential that nurses use critical thinking when planning patient care using the nursing process. This means as nurses, we must use a combination of our knowledge and past experiences with the information we have about a current patient to make the best decisions we can about nursing care.

The nursing process was introduced in 1958 by Ida Jean Orlando. Today, it continues to be the most widely-accepted method of prioritizing, organizing, and providing patient care in the nursing profession.

It’s characterized by the key elements of:

• Critical thinking
• Client-centered methods for treatment
• Goal-oriented activities
• Evidence-based nursing research and findings
• The nursing process helps nurses to provide quality patient care by taking a holistic view of each patient they plan care for.
• The nursing process is an evidence-based approach to caring for patients that helps nurses provide quality care and improve patient outcomes.
• Ida Jean Orlando introduced the nursing process in 1958.
• The primary focus of the nursing process is the patient or client. The process is designed to meet the real and potential healthcare needs of the patient/client and to prevent possible illness or injury.

Leona Werezak BSN, MN, RN is the Director of Business Development at NCLEX Education. She began her nursing career in a small rural hospital in northern Canada where she worked as a new staff nurse doing everything from helping deliver babies to medevacing critically ill patients. Learning much from her patients and colleagues at the bedside for 15 years, she also taught in baccalaureate nursing programs for almost 20 years as a nursing adjunct faculty member (yes! Some of those years she did both!). As a freelance writer online, she writes content for nursing schools and colleges, healthcare and medical businesses, as well as various nursing sites.

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Nursing Process

Introduction.

• The term Nursing Process was first used/ mentioned by Lydia Hall, a nursing theorist, in 1955 wherein she introduced 3 STEPs: observation, administration of care and validation.
• Since then, nursing process continue to evolve: it used to be a 3-step process, then a 4-step process (APIE) , then a 5-step (ADPIE) , now a 6-step process (ADOPIE) Assessment, Diagnosis, Outcome, Identification, Planning, Implementaton and Evaluation.
• Is a systematic, organized method of planning, and providing quality and individualized nursing care.
• It is synonymous with the PROBLEM SOLVING APPROACH that directs the nurse and the client to determine the need for nursing care, to plan and implement the care and evaluate the result.
• It is a G O S H approach (goal-oriented, organized, systematic and humanistic care) for efficient and effective provision of nursing care.
• Goal-oriented – nurse make her objective based on client’s health needs.
• Remember : Goals and plan of care should be base according to clients problems/needs NOT according to your own problem as the nurse.
• Organized/Systematic – the nursing process is composed of 6 sequential and interrelated steps and these 6 phases follow a logical sequence.

Humanistic care

• Plan to care is developed and implemented taking into consideration the unique needs of the individual client.
• plan of care therefore is individualized (no 2 person has the same health needs even with same health condition/illness)
• in providing care, it involves respect of human dignity
• Efficient – plan of case is relevant/ related to the needs of the client thereby promoting client satisfaction and progress.
• Effective – in planning care, utilized resources wisely (staff, time, money/cost)

Aside from GOSH, other characteristic of Nursing Process:

• Cyclic and Dynamic in nature – data from each phase provides the input into the next phase so that is becomes a sequence of events (cycle) that are constantly changing (dynamic) base on client’s health status.
• Involves skill in Decision-making – nurse makes important decisions related to client care, she choose the best action/steps to meet a desired goal or to solve a problem. She must make decisions whenever several choices or options are available.
• Uses Critical Thinking skills – the nurse may encounter new ideas or less-than-routine or non-ordinary situations where decisions must be made using critical thinking.

Purpose of Nursing Process:

• To identify a client’s health status; his Actual/Present and potential/possible health problems or needs.
• To establish a plan of care to meet identified needs.
• To provide nursing interventions to meet those needs.
• To provide an individualized, holistic, effective and efficient nursing care.

Steps/Phases of the Nursing Process:

• Outcome Identification
• Implementation

Reference: NCM (Mrs. Cubon, RN, MAN)

Related Posts

Intramuscular (im) administration, bispectral index monitoring.

Theories and models of nursing and the nursing process

• PMID: 2813849

In summary, nursing models can be evaluated by carefully considering how human beings are conceptualised within a model, how adequately the model guides nurses in the decision-making associated with all stages of the nursing process and how appropriate is the expected role of the nurse. Reference to the criteria for evaluating nursing theory (Fig. 1) demonstrates that not only can nursing models be regarded as the precursors of nursing theory but some evaluative criteria for nursing theory develop from ways of evaluating nursing models (Fig. 2). The essence of this paper has been to consider nursing theory and its place in the current climate of concern both about nursing's professional status and about standards of patient care. The difficulty in defining theory has been briefly explored and suggestions have been made of possible ways of evaluating nursing theory. A distinction has been drawn between nursing models and nursing theory with a rationale for considering nursing models as precursors of nursing theory especially as there are similarities in the criteria used to evaluate them both. The nursing process has been described as a systematic, problem-solving approach to care. It is neither a nursing model nor a theory but rather one way of organising nursing activities. A major dilemma has been omitted from this paper, however, which nonetheless deserves mention here. This dilemma is identified and summarised by Jacox (1974) among others. The question posed is: Can and should we develop nursing theories?' (Jacox's emphasis). The main competing arguments put forward by Jacox are on the one hand that there are no phenomena or activities peculiar to nursing around which nursing theory can develop, and on the other hand that there is a need for a specified body of knowledge to inform nursing practice. Efforts to establish a firmer body of knowledge on which to base nursing practice may help to identify the unique function of the nurse. This will only be achieved if practising nurses take a keen interest in developing rigorous approaches to the evaluation of nursing models and theories. Craig (1980) has linked theory development and its integration with nursing practice to professional survival. If nurses cannot identify phenomena and activities that are peculiar to nursing and if they are not prepared to safeguard these areas of practice, then the future of nursing looks bleak. Project 2000 (UKCC 1986) offers an opportunity for nurses to be more willing and able to critically consider nursing's unique contribution to health care.

• Models, Theoretical*
• Nursing Process*
• Nursing Theory*