The Nursing Process

One of the very first things you’ll learn in nursing school is The Nursing Process. This is a key, fundamental concept that permeates every single thing you do and learn in nursing school. So, it’s important that you know what it is, how it works and why it matters.

The Stages of The  Nursing Process

The nursing process is represented by an acronym (ADPIE) that corresponds with each stage. A = assessment, D = diagnose, P = plan, I = implement, and E = evaluate. You do these stages in the same order every time…for example, you never implement before you assess, and you would never come up with a plan without assigning a nursing diagnosis…you get the idea. Many NCLEX-style text questions can be answered based simply on your understanding of the nursing process. Yes, it’s that important. So, let’s look at it in a little more detail.

• ASSESSMENT: In this stage, you assess the patient and gather data. This can be objective data from your assessment (things you observe such as their vital signs or respiratory effort), or subjective data based on what the patient tells you (pain is a common one).
• DIAGNOSIS: This is where you assign a nursing diagnosis to your problem. We’ll talk more about these in another post…suffice it to say this actually does become second nature after a while.
• PLAN: As you can probably surmise, this is the stage where you develop your plan. Your plan may be long and complex, or it may be something you pull together in a matter of seconds as you’re walking across the room.
• IMPLEMENT: In this stage of the nursing process,  you put your plan into action. This is when you do your actual nursing interventions.
• EVALUATE: How will you know your intervention worked? By re-assessing the patient! In this stage, you evaluate how your patient is doing after you perform the intervention…are they breathing easier? Is their pain better? Before you can move on and do different or more aggressive interventions, you absolutely must evaluate how the ones you’ve already done have worked.

Seems simple enough, right? Well let’s take a look at how it actually works with an example using a fictitious patient:

0645: You get report on your patients….a 36-year old man with cellulitis of the left arm, a 53-year old woman s/p total hysterectomy who is on POD 2, a 77-year old male with pneumonia and a 48-year old man with diabetic ketoacidosis and a massive foot ulcer. The unit is fully-staffed, you’re slated to get all your breaks for the day, and the charge nurse brought in a box of fresh croissants. It’s shaping up to be a good day!

0700-0800: You perform your initial assessments on all your patients. Everything is hunky-dory.

0930: You are smack in the middle of your first med pass when your hysterectomy patient complains of shortness of breath. You now implement the first stage of the nursing process…ASSESSMENT. You listen to her lung sounds (they are very diminished at the bases) and you put her on the monitor to assess O2 saturation (87%). You quickly move on to stage 2 and assign her a nursing DIAGNOSIS (ineffective gas exchange). Next, is stage 3…PLAN. For this patient, your plan is to add supplemental oxygen. So, as you place the patient on a nasal cannula you are performing stage 4…IMPLEMENTATION. You give the oxygen a couple of minutes to do its magic, and then you go to stage 5…EVALUATE. You check her O2 saturation levels again…she’s come up to 89-90%…good not great. Hmmm…what now?

0940: You pull up the patient’s chart and take a quick look. You see that the patient’s O2 saturation level has been in the high 90s on room air for the last few days. Hmmm….so this is definitely not her “normal.” You also notice that the patient has been refusing her pain medication for the last 12 hours. Time to get back in and go through ADPIE again.

0945: You now suspect that the patient’s low O2 saturation levels and SOB might be due to pain. So, again you ASSESS…it always starts with assessment. You ask the patient about her pain and she tells her her pain level is 7/10. When you explain that her SOB is likely due to her inability to take a deep breath secondary to her very high pain level, she tells you she doesn’t want to “get addicted” to pain meds and hasn’t taken any since the night before. You now move on to the D stage…DIAGNOSIS. Now you have two diagnoses to work with! 1) Ineffective gas exchange secondary to abdominal pain as evidenced by patient stating pain level 7 out of 10; and 2) Knowledge deficit related to pain medication. (Yes, we will talk about the dreaded nursing diagnosis in another post!).

Just like before, you come up with a PLAN…for starters you’ll need to educate the patient on why pain medication is important, and secondly you need to get some pain medication in her so she can take a deep breath, cough and open up those collapsed alveoli. So,  you IMPLEMENT with some patient education…she agrees to take a “small dose” of morphine and you IMPLEMENT the second part of your plan as you administer the medication via IV.

1000: You let the morphine take effect, and move on to the last stage…EVALUATION. You measure the O2 saturation level…it’s 99% on the nasal cannula. You ask the patient her pain level, she states it is 4/10…a level she states she can tolerate AND cough/deep breathe. You have her splint her belly and cough a few times (which technically brings you back around to IMPLEMENTATION again) and listen to her lungs…her lung sounds are more pronounced in the bases and as you continue to EVALUATE the patient, you are able to wean down the oxygen until she’s back on room air and resting comfortably.

1005: And, of course, you chart all of it! Now go have a croissant and put your feet up for your morning break 🙂

Now that you understand the basics of the nursing process, you should be able to start applying it in clinical AND when going through case studies or taking exams. You got this!

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