Nursing Process

Satisfactory Essays
Nursing Care Plan- Assessment & Diagnosis
Anabel Debrand
07/05/2013
Nursing Roles I
Instructor- Neala Asser

Abstract In this document you will learn about the Nursing Process and how it works. This process is the way every nurse is supposed to take an event into action and encounter the situation, whether evidence- based or research.

Nursing Care Plan- Assessment & Diagnosis
The Nursing Process is a patient centered method of caring, that provides a framework to nursing care. This process involves five major steps of Assessment, Diagnosis, Planning, Implement/ Intervention and Evaluation. These steps are known as the “ADPIE”. In this document we will only be focusing on the first two steps which are Assessment and Diagnosis.
Nursing Assessment (ADPIE) is the first step in the nursing process. This step can be viewed as an interview process in which the nurse is gathering information from the patient. Observation and asking specific questions are two of the ways a nurse gathers information. The nurse will have a better understanding of the patient’s psychological, physiological, sociological, and spiritual status. There are many ways this data can be collected. Generally, nurses will conduct a patient interview. Physical examinations, referencing a patient's health history, obtaining a patient's family history, and general observation can also be used to gather assessment data. Physiological signs that the nurse would look for would be nerve functions, sleep activity, vital signs, allergies, drug use, chronic condition or any signs of physical abuse. For psychological, sociological and spiritual understandings, the nurse would look for emotional tone, occupation, family ties, financial support and responsibilities. This information helps the nurse analyze the data collected in order to begin the next step which is nursing diagnosis.
Nursing Diagnosis (ADPIE) is the next step in the nursing process. This phase is critical to the nursing

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