1. Brief Overview of Nursing Process
Gail Ladwig, RN, MSN
Marina Martinez-Kratz MS, RN, CNE
This is a brief overview of the nursing process.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

2. Introduction
History: Labeled the “Nursing Process” in by Lydia Hall.
Nursing process is how nurses:
Think.
Identify patient problems.
Determine patient outcomes.
Prioritize patient care.
The Nursing Process has been used in nursing for a very long time. It is how nurses think and how they identify client problems, determine outcomes, and prioritize nursing care for clients. What nurses do was officially “labeled” as the Nursing Process in the 1950s.

3. Clinical Reasoning and Multiple Ways of Thinking
Nurses use multiple types of thinking in all steps.
Process includes the client.
Confidentiality is respected; the Health Insurance Portability and Accountability Act (HIPAA) of 1996 is followed.
The Nursing Process uses critical thinking in all the steps.
The process is ideally done in cooperation with the client. When this is not possible, a designated person must be identified. At all times the client’s rights and confidentiality are respected.

4. Steps of Nursing Process
Five-step process is based on the scientific process.
The acronym ADPIE is a useful way to remember the steps of the nursing process:
A: Assessment
D: (nursing) Diagnosis
P: Plan
I: Implementation
E: Evaluation
The Nursing Process is a five-step process based on the scientific process. The acronym ADPIE is a useful way to remember the steps of the nursing process. A = Assessment, D = (Nursing) Diagnosis, P = Plan, I = Implementation, E = Evaluation.

5. Step One: Assessment
Follow the format used by the facility or educational setting.
Identify yourself, and then gather the necessary information.
Perform a physical assessment.
Obtain an accurate history.
Review medical records and diagnostic tests.
Collaborate with entire health care team and the client’s significant other, if appropriate.
The first step of the Nursing Process is the Assessment. It is also a part of the process that is continuous throughout the total care of the client. The client is assessed initially and then continually as care is administered and as the client’s condition changes/progresses.
There are many assessment forms available to ensure that appropriate information is gathered and that appropriate information is not missed. There are several tools written by nurse leaders. They are all designed to assist the client to the highest level of health.
Assessment is the initial step of the nursing process. During this step information about the client is gathered. The information should encompass the “whole” person and help identify areas that the client deems problematic. The client’s strengths also need to be identified. This is important because strengths can be supportive in changing problems and enhancing quality of life for the client. As the nurse assesses the client, critical thinking is used to determine appropriate and relevant data.
Assessment information is obtained from many sources. The first and most important source is the client. A thorough history and physical examination should be done by the nurse. Medical records are reviewed; diagnostic tests that have been ordered by the physician/nurse practitioner are also reviewed. The entire health team is essential to obtain a complete assessment. Significant others may be included if appropriate.

6. Step Two: Nursing Diagnosis
Two-part system
Nursing diagnosis (label from the NANDA-I list)
Related to (r/t) statement (What is contributing to the nursing diagnosis?)
Three-part system
P(roblem) (label from the NANDA-I list)
E(tiology) or r/t factor (What is contributing to the nursing diagnosis?)
S(ymptom) (signs and symptoms, or as NANDA-I describes them, defining characteristics taken from assessment information)
The first part of the Nursing Diagnosis statement is the nursing diagnosis taken from the NANDA-I list. The etiology is listed in the Ackley/Ladwig text or can be found at the EVOLVE care plan constructor on the page (site) that contains the nursing diagnosis label. The defining characteristics will be at the same page/site. Compare what you identified in the assessment with the information in the text or at the EVOLVE website.

7. How to Make a Nursing Diagnosis
Look for common patterns in the assessment.
Cluster or group common patterns.
Verify defining characteristics.
Identify possible nursing diagnosis.
Use clinical reasoning skills to determine an accurate diagnosis. Ask:
“Does the client information match NANDA-I information?”
“Is it important to the client?”
“What other information do I need?”
Clinical reasoning is applied to the assessment information to formulate a nursing diagnosis. Is the information in the assessment? Would a nursing intervention support a change? Compare the data with the NANDA-I definition. Do the signs and symptoms of the client match the defining characteristics supplied by NANDA-I?

8. “Related to” Phrase or Etiology
Relationship to nursing diagnosis
Types of nursing diagnoses:
Independent
Collaborative
Etiology: related factors that appear to show some type of relationship with the nursing diagnosis.
Ask: Can the nurse treat the client with this Dx independently?
Ask: Is medical intervention or assistance from other health team members required?

9. Defining Characteristics Phrase
Signs and symptoms are identified during the assessment.
The phrase as evidenced by (AEB) may be used to connect the etiology (r/t phrase) with the defining characteristics.
Example:
Activity intolerance r/t generalized weakness AEB complaints of fatigue and a shortness of breath (SOB) with activity.
Defining characteristics are the signs and symptoms that were identified in the client assessment.
When connecting them to the nursing diagnosis label, the phrase as evidenced by is often used to demonstrate the association between the signs and symptoms and the Dx.

10. Writing a Nursing Diagnosis Statement
P—Choose the label.
Nursing diagnosis
E—Write an r/t phrase.
Etiology
S—Write the defining characteristics.
Signs and symptoms
After you have selected the nursing diagnosis and are satisfied that the statement meets all the appropriate criteria, it needs to be documented. Use the form/system that your institution has supplied.

11. Step Three: Planning Prioritizing the nursing diagnosis Outcomes
Maslow’s hierarchy
Safety
Outcomes
Interventions based on evidence
This is a very important step of the Nursing Process. You have all your data and you have made a diagnosis, now what? A plan is needed.
The nursing diagnoses need to be prioritized. Maslow’s hierarchy is one way to prioritize so that basic possible life-threatening needs are addressed first. Safety needs are another way to prioritize diagnoses.
Mutual outcomes need to be determined, and a way to accomplish and measure the outcomes must be developed.
Finally interventions based on evidence need to be selected. This is where the concept of Evidence-Based Nursing is used. Interventions that have research to support them are used.

12. Outcomes Developed as a result of prioritizing the nursing diagnosis
Influenced by nursing interventions
Measurable
Compared with baseline over time
Client involvement
Outcomes may be selected from standardized nursing language. Examples are in the care plan that you have selected in the Ackley/Ladwig text or care plan constructor site. A list is also available at the EVOLVE website.
Determine with the client what is appropriate for the client. Set times when the outcomes will be measured.

13. Outcomes—cont’d Nursing outcomes classification (NOC):
Includes the definition.
Uses five-point Likert-type rating scale.
Assists in recording change after the intervention.
Increases client motivation to achieve outcomes.
When writing an outcome statement, ask:
Is it client centered?
Is it measurable?
What is the time frame?
Is it relevant to the nursing diagnosis and client symptoms?
NOC outcomes are measured along a continuum so they can be measured at any time. They are neutral and may be used to help set goals.
You may also select client outcomes listed in the Ackley/Ladwig text or on the EVOLVE website.

14. Interventions
Interventions include any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance client outcomes.
Clear interventions result in successful client outcomes.
Evidence-based nursing equals effective interventions.
Use interventions that are based on research.
Best practices equals best care and outcomes.
Interventions may also be selected from a list of standardized nursing language (NIC). There are samples with each nursing care plan in the Ackley/Ladwig text and on the care plan constructor site. A list is also available on the EVOLVE site.
There are also many evidence-based interventions listed with each nursing diagnosis. Interventions should be clearly written so that everyone involved in the client’s care knows how to care for the client. They are like a “road map.” The clearer the map, the easier it will be to get to the destination. In this case the destination would be to accomplish the goals that the client wants to accomplish.

15. Interventions—cont’d
Independent
Collaborative
Nursing intervention classifications (NICs):
Are comprehensive
Are standardized
Cover all nursing specialties
Interventions may be done independently by the nurse, or the nurse may collaborate with the physician or other health care professionals.
Standardized interventions from NIC may be used.

16. Putting It All Together
Write the care plan:
Prioritization of nursing diagnosis
Outcomes
Interventions
Document and share.
The information that you have collected and the plan that you made must be documented.

17. Step Four: Implementation
Initiation of care plan
Performing interventions
Assessing effectiveness
Documentation
Important. When you have completed the interventions and the other steps of care, you must document and report any pertinent information to the appropriate members of the health care team.