The nursing process can be remembered by the common mnemonic ADPIE, which stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation.
The assessment portion of the nursing process is where the nurse will collect data about the patient. This information will encompass physical findings, psychological, cultural, social, family, and nursing histories as well as accessing the medical record and obtaining diagnostic test results.A nurse should not implement interventions until a complete assessment has been done. Exceptions are only in scenarios where the patient will be at risk of immediate injury or death.
The nursing diagnosis is formed after completions of a comprehensive nursing assessment. Nursing diagnosis' are developed by NANDA (North American Nursing Diagnosis Association) and should be prioritized based on Maslow's Hierarchy of Needs.
The planning step of the nursing process includes developing an individualized care plan, setting goals, and identifying expected outcomes. Setting priorities of the nursing diagnosis' is an important step in the plan of care. The planning step of the nursing process includes developing an individualized care plan tailored to the patient, setting short-and-long-term goals, and identifying expected outcomes using the SMART system, an acronym used to set realistic and specific goals, which stands for specific, measurable, attainable, realistic and time-oriented.
Implementation is the step of the nursing process where your prioritized plans are carried out. Be sure to involve both the patient and family in active care. The nurse should always use therapeutic communication techniques for communication during implementation.(Notes: This is the step where we actually intervene to help them, give drugs, educate, monitor.)
Evaluation is the step where the nurse determines if the patient has met the goals in the patient's plan of care. If the patient did not meet the goals, then the nursing process would begin over and reassessment of the client is completed. Be sure to include reasons why the goals were not previously met and modifications to the plan of care to ensure new goals would be completed.
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