Nursing Process: 5-Step Process
Gail Ladwig, RN, MSN, CHTP
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Nursing Process: Definition
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An organizing framework for professional
nursing practice
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Used in nursing to identify and treat the
nursing diagnoses (problems) of a client
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Critical Thinking and the NP
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Decision making for and with the client
The nurse processes and interprets the
information that is gathered while performing
the steps of the nursing process.
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Nursing Process: Quote
Caring is major part of the process
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“Caring is essential to curing and pervades
all efforts to help an individual recover after
an illness and be cured” (Leninger, 1996)
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Nursing Process: Quote
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According to Leninger (1996), “Caring is the
most important and central focus of nursing”
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Nursing Process: Quote
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Watson and Ray (1988) advocate that “we first
love and care for ourselves, so as a beginning
nurse you are to believe in yourself, identify your
strengths, and put your abilities to work.”
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Nursing Process: 5 Steps
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Use the acronym ADPIE
1.
2.
3.
4.
5.
Assessment
Diagnosis
Plan
Implementation
Evaluation
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Step One
Assessment
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Assessment
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Initial step of the nursing process
Collection of information about the client
Holistic and detailed
Supports critical thinking
Determines problems and strengths
Ongoing during all phases of nursing process
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Step One: Assessment
Method
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Assess the client: perform a thorough holistic
nursing assessment
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Use the format adopted by the facility or
educational institution
• Nursing assessments may be based on conceptual
models: Gordon’s functional health patterns, Orem’s selfcare model, or Roy’s adaptation model
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Assessment
Sources of Information
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Nursing assessment/heath history: client
Physical assessment: client
Medical records
Diagnostic test results
Health team members
Significant others if appropriate
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Obtain an Accurate Health History:
Sample Questions
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Ask open-ended questions:
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“Describe what you are feeling.”
“Tell me about these symptoms?”
“How does it affect your daily routine?”
“What can we help you with?”
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Physical Assessment
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Perform a thorough physical assessment
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Medical model: head to toe or body system
Carefully assess each area for normal and
abnormal findings
Inspect, auscultate, palpate, and percuss
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Critical Thinking
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Look for normal and abnormal findings
Validate the data with the client
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Validation
• “This is what I have noticed.”
• “Does this describe how you feel?”
• “Tell me more.”
• “What can I do to help?”
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Critical Thinking (Continued)
Using the assessment information
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Organize the information
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Identify patterns in the assessment (highlight or
underline problems)
 Make a list of all problems and potential problems
 Group like problems together
 Make initial inferences or impressions
 Prioritize the problems
• Use Maslow’s hierarchy
 Record and report the information
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Immediate Reporting
of Assessment Information
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Report and record information that requires
immediate action.
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Some examples
• Sharp unrelenting pain
• Vital signs greatly deviated from normal
• Change in level of consciousness
 When in doubt, report.
 Be
prepared to immediately follow
instructions that are given.
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Documentation
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Record all information obtained from the
health history and physical assessment.
Many institutions use computers for this
purpose.
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Confidentiality
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Share only information that is of benefit to the
nursing and medical team for planning care.
Always keep in mind that HIPAA laws must be
followed.
Keep notes safe.
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Do not leave at site of interview.
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Confidentiality (Continued)
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Client’s name should appear only on agency
documents (do not put client's name on any
notes used for classroom work).
Follow Health Insurance Portability and
Accountability Act (HIPAA) guidelines regarding
client confidentiality.
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Step Two
Nursing Diagnosis
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Nursing Diagnosis
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Clinical judgment
Individual, family, or community
Response to actual or potential health
problems or life processes
Basis for outcomes and interventions
The nurse is accountable.
(NANDA-I [NANDA-International], 2009)
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Nursing Diagnosis List
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Select the appropriate nursing diagnosis for
the client from NANDA-I’s approved list.
Nursing Diagnoses: Definitions and
Classification 2009
List of 203 “approved nursing diagnoses”
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Critical Thinking
and Nursing Diagnosis
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Based on assessment information
Information is analyzed (Questions to Ask)
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Can a change occur with a nursing intervention?
Does it fit the NANDA-I definition?
Are the defining characteristics in the
assessment?
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Make a Nursing Diagnostic
Statement: PES
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Problem/nursing diagnosis
Etiology/related to statement
Signs and symptoms/defining characteristics
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Nursing Diagnosis: Critical
Thinking
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Does the selected diagnosis fit the NANDA
definition?
Are the defining characteristics in the
assessment?
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Document Selected Nursing
Diagnosis on Nursing Plan of Care
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Step Three
Planning
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Planning
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Step done after the nursing diagnosis is
determined
This step consists of writing measurable client
outcomes and nursing interventions to
accomplish the outcomes.
These outcomes and interventions are
designed to change the client’s nursing
diagnosis/problem.
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Planning Steps:
Outcomes, Interventions
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Write measurable client outcomes.
Identify nursing interventions to accomplish
the outcomes.
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Planning: Critical Thinking
Outcomes and Interventions
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Outcomes
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What does the client hope to accomplish?
How should these client outcomes be prioritized?
How will the outcomes be measured?
How long will it take?
Interventions
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What nursing interventions can the nurse do to help the
client with satisfactory outcomes?
Who will assist the client?
• The nurse?
• Ancillary personnel?
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Definition: NOC (Nursing Outcome
Classification)
Standardized Language
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An individual, family, or community state,
behavior, or perception that is measured along a
continuum in response to nursing intervention(s)
The outcomes are variable concepts that can be
measured along a continuum.
Outcomes are stated as concepts that reflect a
patient, family caregiver, family, or community
actual state rather than expected goals.
(Moorhead, 2004)
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Planning: Outcomes
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Set client-centered short-term and long-term
goals/outcomes.
Prioritize by what is most important.
Use Maslow’s hierarchy.
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Outcomes: Critical Thinking and
Outcomes
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Questions
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Does it come from the nursing diagnosis?
Is it measurable?
Does the client agree to it?
Is it realistic?
Is it attainable?
Is there a time frame?
Does it provide direction for care?
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Document Selected Outcomes
on Nursing Plan of Care
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NIC
(Nursing Intervention Classification)
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The nursing interventions classification (NIC) is
a comprehensive, standardized language
describing treatments that nurses perform in all
settings and in all specialties .
The classification includes both physiological
and psychosocial interventions and covers all
nursing specialties.
(Bulechek, Butcher, McCloskey Dochterman
2004)
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Interventions:
How to Select Appropriate Ones
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Criteria for interventions
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Activity done for and with client
 Accomplishes outcomes
 Removes or reduces related factors that
contributed to the nursing diagnosis
 Individualized
 Specific/safe
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Interventions (Continued)
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Road map to guide nursing care
The more clearly a nurse writes an
intervention, the easier it will be to complete
the journey and arrive at the destination of
successful client outcomes .
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Evidence-Based
Nursing Interventions
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A set of interventions or guidelines that have
been shown to be effective in helping clients
EBN looks at standard protocol and determines
if the protocol is effective based on gathered
evidence.
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Planning
Interventions: Critical Thinking
Questions to ask
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ASK
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What nursing interventions can the nurse do to help the client
with satisfactory outcomes?
Who will assist the client? The nurse? Ancillary personnel?
What equipment is needed?
How long will the intervention take?
How often should the intervention be done?
What is the evidence to support its effectiveness?
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Document Interventions on Nursing
Plan of Care
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Step Four
Implementation
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Implementation
ACTION
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Initiation of the nursing care plan
Performing the nursing interventions
Delegation of appropriate nursing
interventions
Using skills
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Psychomotor
Interpersonal
Cognitive
Performing continuous assessment
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Implementation: Critical Thinking
ASK
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How did the client tolerate the intervention?
Were there any identified problems?
Was any additional equipment needed?
Was the time frame appropriate?
Were the appropriate personnel involved?
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Report
and
Document
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Step Five
Evaluation
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Evaluation
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Although evaluation is listed as the last phase
of the nursing process, it is actually an
integral part of each phase and something
that is done continually.
Client’s outcomes are evaluated to see if
they are satisfactory.
If the outcomes were not satisfactory, then
the nursing process is begun again with
assessment to determine the reason why the
outcomes were not satisfactory.
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Evaluation: Critical Thinking
ASK
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Check the client outcomes.
Were the outcomes satisfactory?
Is an additional assessment needed?
Were the outcomes realistic?
Was the right nursing diagnosis selected?
Does the nursing care plan need to be
modified?
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Evaluation: Critical Thinking
(Continued)
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When using EBN, it is at this point that it is
determined whether the practice that was
followed was effective.
Necessary revisions may be made at this
time.
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Summary
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Review
Steps of the nursing process (ADPIE)
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Assessment
Diagnosis
Planning
Implementation
Evaluation
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Final Reminder
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Document and report.
“If you didn’t chart it, you didn’t do it.”
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Good Job
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You have mastered the nursing process.
You have delivered safe, effective care to
your client.
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Be proud of your work and profession.
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References
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Bulechek G, Butcher H, McCloskey
Dochterman J: Nursing intervention
classification (NIC), ed 5., St. Louis, Mosby,
2008.
Leininger M: Culture care theory, research, and
practice. Nurs Sci Q 9(2): 71 – 78, 1996.
Moorhead S, Johnson M, Maas M et
al: Nursing outcomes classification (NOC), ed
4., St. Louis, Mosby, 2008.
Watson J, Ray M (Eds.): The ethics of care
and the ethics of cure: Synthesis in chronicity.
New York, NLN, 1998.
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