Master the NURSING PROCESS (TOP TIPS)

Learn the five steps of the nursing process: Assessment, Diagnosis, Planning, Implementation, and Evaluation. Use a head-to-toe assessment pattern to build muscle memory, reference the NANDA-I list for diagnoses, and distinguish between patient goals and nursing interventions. Reassess after every intervention and document everything.
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In this video, I'm giving you my top tips for mastering the nursing process. I've also got some amazing cheat sheets to give to you to help you out with the nursing process. So be sure to stick around until the end of the video so you can get those. Now hit the subscribe button and click the notification bell and let's dive in. So the nursing process goes like this. Assessment, Diagnosis, Planning, Implementation and Evaluation. ADPY for short. I did a whole breakdown on what each of these steps is here in this video. So if you want to deep dive into what to do in each step of the nursing process, be sure to check that video out. In this video, I'm going to build on that give you my top tips to help you master each step of the nursing process. So let's start with the nursing assessment. Now, the nursing assessment is everything in nursing school and in nursing, it's the most important thing that you will ever do as a nurse. Now, assessing your patient means that you're collecting data like taking their vital signs and listening to their lungs, things like that. And you're also critically thinking along the way. Because you're constantly thinking about the other things that you might need to assess for and really trying to figure out the underlying problem for that patient and then how to treat it. You're always going to stay on your game. Notice when your patient's condition changes or when just something feels off. This is all part of critical thinking during your nursing assessment. I have these videos all about critical thinking in nursing school, so be sure to check those out after you watch this video. I will put a link to all of those in the description below to make them easy for you to find. So don't worry, I've got your back. When I started nursing school, I honestly had no idea that the nursing assessment even existed. I thought the nurses just took things like vital signs, gave medications. That was a rude awakening because the nursing assessment is just plain hard. It is so hard to learn the process of assessing a patient. So my first tip to make it easier for you is to follow the same pattern every single time. Find a system and flow that works best for you and do it the same way every time you assess a patient. This will help you to not forget anything because it will just become muscle memory for you. I will never forget my first patient assessment. I was a hot stinking mess. It pretty much took the whole day to get all the info I needed on my patient because I kept forgetting things and then having to go back into her room to ask her More and more questions. Thankfully, that was our only task for that day, was to work on our assessments. That was a rough one. So this is why we call the nursing assessment the head to toe assessment. Because we literally go from head to toe. That's one of the easiest patterns to follow. Start at the head and assess down to the toes. I know how scary the nursing assessment is, so that's why I created a full nursing assessment transcript for you to follow. This is your complete guide to doing the head to toe assess Patient. I walk you through step by step, what to say and what to do. It is amazing. Friend. Do not miss this nursing assessment transcript. Print it off. Use it as you practice. It will help you learn it faster and get more and more confident without forgetting anything, like I did. The link is down below for you to check it out. Now let's talk about the nursing diagnosis. Now, some students get confused and think that this is a medical diagnosis, but they are wrong. The nursing diagnosis is the patient's recess response to what is going on with them. So instead of it being a medical diagnosis like a heart attack or mi, the nursing diagnosis could be something like anxiety if the patient is feeling anxious about that diagnosis. Now here's the best news for you. Nursing diagnoses are standardized. They're actually created by the North American Nursing Diagnosis association called Nanda International, and they give you the list of all these nursing diagnoses to use, so you don't need to make them up or anything. So my best tip for you is to look through your nursing textbooks for this list of nursing diagnoses. Just pick from that list when you do your patient reports or your care plans. And if your books don't have the full list, this is the book I recommend, the Nursing Diagnosis Handbook by Ackley and Ladwig. It's fantastic. On the inside cover, it has all of the diagnoses listed for you. And then as you scroll through it, it has every single diagnosis. It basically writes your care plans for you. So if you do not have this book yet, I would seriously recommend getting it. It's going to save you a gazillion hours writing your care plans. Now let's talk about the planning step of the nursing process. Now, planning just means that you're setting a plan of action for how you're going to help your patient meet their goals and get better. So this is where you write out your patient goals and your nursing interventions. We talk more about how to write patient goals and nursing interventions in these videos here. And if you are a nursing SOS member. Be sure to check out the whole care plan course that we have for you as well, where I walk you through step by step, how to write patient goals and nursing interventions and ace your care plans in nursing school. The biggest thing that I see nursing students get stuck on here is that patient goals are always written as what the patient will do, and the nursing interventions are always written as what you, the nurse, will do. So the patient goals will be things like the patient will have clear lungs by 1900 tomorrow or the patient will walk 20ft down the hallway and back without needing to sit down. The patient goals are written as what the patient will do. Now, on the other hand, the nursing interventions are written as what you, the nurse, will do. This is not about what the patient is going to do, which means things like giving medications, consulting with maybe speech, language pathology or other team members on the healthcare team, educating the patient on healthy lifestyle modifications, monitoring the patient's intake and output, things like that. These are all things that you, the nurse, will do. So when you go to clinical or write your care plan or take your nursing process exam, just remember that the patient goals are things that the patient will achieve. And then the nursing interventions are the things that you, the nurse, will do to help the patient achieve their goals. And now implementation is where you make it all happen. All of those interventions that you just planned out, you're going to do them. And my best tip for you here is to take charge and volunteer for every opportunity you get. If you see a nurse about to put in an iv, volunteer to do it if your school allows you to, or if a nurse is about to empty a drain, volunteer to help. Seriously, friend, take every opportunity you can to practice your skills at clinical. I know how scary it is to put yourself out there, but you have two choices. Either you practice it now when you're in school and working under a nurse, or you practice it at your first job when it's just you. I would take option number one because you least have someone there to give you feedback from it and it makes it a lot less stressful. Now the next step of the nursing process is evaluation. This is basically you assessing your patient all over again. You will evaluate if your patient met their goals or not. You'll figure out what needs to change if they didn't meet their goals or or what new goals should be created. And the biggest thing that I want you to remember here is that you should always reassess your patient. Always, always, always after you do any treatment or intervention. And also during your rounds, make sure that you're always, always assessing them. If you're a Nursing SOS member, check out this video inside the Nursing SOS Membership community on how to chart your reassessments. This is super important because we want to make sure that the treatment is working and that intervention is working and that there weren't any adverse effects. So for example, if you gave your patient a medication, you want to reassess them to make sure that a that medication worked and gave the desired effect, but also B that it didn't cause any problems. So it's really important that you always reassess your patient and document that you reassessed them. Now, along with the nursing assessment transcript cheat sheet that I've got for you, I have a whole other T sheet that outlines this nursing process for you. So make sure that you snag both of those and take them to clinical and lecture class with you. I put the links to those in the description below. And in the next video we are starting a brand new series on how to study in nursing school. So next week's video I'll be giving you my top tips for how to get straight A's in nursing school. You do not want to miss this one. Now click on one of these videos right over here to keep rocking nursing school and go become the nurse that God created only you to be. And I will see you in the next video. Take care friend.










