The nursing process has five key steps in it. There is an acronym to remember these by steps by; it is ADPIE. Assess Diagnose, Plan, Implement, and Evaluate. The assessment step is exactly as it states; a nursing assessment. The nurse assesses the patient and gathers information to make a diagnosis. The next step is diagnosing; in which means forming a nursing diagnosis based on subjective and objective data; and on the patient history. Once a nursing diagnosis is formed; the nurse must plan for patient care and make a care plan for treatment, setting appropriate and measurable goals to be reached. Next is implementation. In this step of the nursing process the nurse implements, or puts into action the plan of care. Lastly is evaluation; which may be last in the nursing process but needs to be done throughout the whole process. In the sense of it being stated as the last step though, it references measuring the outcome of the goal and asking some important questions. Was the goal met? Does anything need to be revised, added or removed? How has the patient responded to the care plan?
I believe the nursing process is a great foundation to start with when beginning care with all patients. It sets clear guidelines to make rational decisions and ensure measured outcomes for each and every patient. Nursing Diagnosis Handbook, 9th edition Section I Pages 1-12 used as reference.
The Nursing Process
Nursing Diagnosis Handbook, 9th edition Section I Pages 1-12 used as reference.