Nursing Process Steps (and CRITICAL THINKING TIPS!)

In this video, I am going to walk you through the nursing process step by step. The nursing process is one of those topics that just about every nursing student gets confused about when you first start nursing school. So my friend, do not worry, I will walk you through it step by step so you'll understand it. And be sure to watch the entire video because there is a little change to the nursing process that you might not know about that some schools use. And I'll let you know what that is. So let's dive in. Welcome back my friend. My name is Christina Rafano from nursingsos.com and you are watching the nursing school show where we teach you how to raise your grades for nursing school and have more free time as well. And one of the topics that you must know inside and out during nursing school is of course the nursing process. So the nursing process is really just a step by step system for what you will do as a nurse. And you know how much I love step by step systems is how I teach all the time. All you need to do is follow the steps and you will be golden. And of course you know me and you know that I have this laid out on a free cheat sheet just for you too. So be sure to download that after you watch this video. The link is down below in the description box. We'll put it down there. So let's walk through exactly what the nursing process is, how to use it in nursing school and at clinical and what you need to know about it for your nursing Nursing School exams. So there's a handy dandy mnemonic for the nursing process. You may or may not have heard it before. It's called adpie A D P I E. Now this stands for Assessment, Diagnosis, Planning, Implementation and Evaluation. And there's a small change to this that some nursing programs use. Yours might be one of them. And I'll let you know what that is when we get there. So be sure to watch out for that. So let's walk through each of these steps of the nursing process. You can fully understand it now that the first step is the A in ADPY assessment. The assessment is by far the number one most important thing you will ever do as a nurse. This is really where nurses shine. And knowing how to assess a patient really well is what's going to set you apart. Anyone can give an injection or start an IV or give meds, but it's your skills with the nursing assessment, your nursing assessment skills that will really help you stand out from the crowd and put you in the forefront of Your nursing school class. So what exactly is the nursing assessment? The nursing assessment has really two main components. Number one is collecting data, meaning that you're taking vital signs, you're getting the patient's history, you're asking them questions about their lifestyle and you're performing your head to toe assessment or a focused nursing assessment. And then number two, critical thinking. You've heard it before. So as you're performing your nursing assessment, so you're taking your vital signs, you're asking your pat urgent questions and you're performing that head to toe assessment. As you're doing that, you are constantly thinking about what could be going on with them and what you need to assess for further. Now this is that critical thinking piece. In nursing. You are always on your game, noticing slight changes in your patient, how they respond to questions, respond to things, and just being aware of if something just feels off to you. Now let's talk about that first part, the data collect. Now this just means that you're collecting general data from your patient. You'll need to of course take their vital signs, complete your head to toe assessment, maybe a focused assessment, and then ask them about their patient history, of course. But you'll also want to ask questions about their day to day activities, their spirituality, their psychological health, their relationships with others and their family and their major life stressors. So the nursing assessment actually go goes way beyond just performing the physical head to toe assessment on your patient. You are actually asking a lot of really personal questions to them so that you can plan their care better. Now let's talk about that critical thinking piece of the nursing assessment. This is where a lot of students get a little freaked out. But don't worry, you will always be thinking about and pondering what the underlying problem is or what it might be be and then trying to figure out if you need to assess a certain area further. That's all it means. Now I always like to use this example. So let's say that you're taking care of a cardiac patient and you notice on their heart rate monitor that their heart rhythm is going all crazy. So you run into their room all dramatic. But when you get there and they're talking to you and they're moving around, are you going to shock them right away to get their heart back into a normal rhythm? No, of course you are not. You are going to say, say they're really moving around a lot. I think I will have him sit still for a minute and see what his heart is actually doing. Right. So that is critical thinking, my friend. You are not just basing everything off the monitors, but you are actually looking at everything holistically looking at your patient and assessing the whole situation. So here's a bonus tip for you when it comes to the nursing assessment assessment. Always, always, always assess your patient and not the monitors. If your patient is alert and they're oriented and they're talking to you, don't just call a code because the cardiac monitor was telling you that a code was necessary. Use your awesome critical thinking skills and assess your patient. Look at your patient, not the monitors. So in the nursing assessment step of the nursing process, that A in adpy, you are going to be asking your patient questions, you're going to be doing your head to toe assessment and then of course using your awesome critical thinking skills to get an idea of what might actually be going on with them, with the underlying problem is and then what you need to assess for further. So now let's move on to the D, the diagnosis step of the nursing process. That D in adpy. When you hear diagnosis for the first time, you're probably thinking of a new medical diagnosis, something like heart failure or stroke. But this is not the case in nursing. The nursing diagnosis is not a medical diagnosis. The nursing diagnosis is the patient's response to what is happening with them. So for example, the nursing diagnosis is not a medical diagnosis such as asthma. But if your patient with asthma is really restless, really nervous and anxious, your nursing diagnosis could be something like anxiety because that is the patient's response to their asthma. So if you're taking care of a patient who had a stroke and then can't use the left side of their body, you may write a nursing diagnosis of impaired physical mobility or grieving or impaired swallowing, perhaps depending on their situation, because those are patient reset responses to their stroke, but it's not the medical diagnosis of the stroke itself. Does that make sense? So the D and ADPIE is the diagnosis step of the nursing process and it is not a medical diagnosis. It is a nursing diagnosis which is the patient's response to what is going on with them. Now, it's important to note that the nursing diagnoses are actually standardized. There is a organization called the North American Nursing Diagnosis association or NANDA International, or NANDA I for short. And they have made a list of these standardized nursing diagnoses that you can use so you don't make them up. This actually makes it way easier for you because all you need to do is choose from that list. You don't need to create them from anywhere. Now, one of the most common questions that I get from nursing students is, where in the world do I find all of the nursing diagnoses? There's random ones in your textbook, but where can I find the whole list? So my answer is always, always, always. This book, the Nursing Diagnosis Handbook by Ackley and Lodwig, it has all of the nursing diagnoses listed here in the front and they all are explained throughout the book. Now, this book literally writes your care plans for you, my friend. I highly recommend it because you can go through and check out all the nursing diagnoses, all of the goals, patient goals, nursing interventions that you could do. It really helps you wr care plan and understand the nursing diagnoses better. So the Nursing Diagnosis Handbook by Ackley and Ludwig, highly recommended. And of course, if you want a deep dive on care plans and how to write them, better be sure to check out this video that we have for you that'll walk you through it. Now, let's move on to the next step of the nursing process. Now, you're probably thinking that it's that P in adpy, right? Well, here is that little change that I talked about earlier. Now, some nursing schools actually put an O in first, making it add O PI. And the O in atto, PI stands for outcome identification. Outcome identification in the nursing process means that you decide what it looks like when the patient actually meets their goal. It's basically goal setting. So up until now, you have assessed your patient, you've come up with a nursing diagnosis for them, and now it's time to create some goals for them to achieve. And these are the outcomes that you hope to see, the goals that your patient wants to meet. And you'll also describe exactly what it looks like when they meet that goal or that outcome. So let's say you have a patient who is needing to practice walking after surgery. You may set a goal for them to walk the 10ft from the bed to the bathroom and then back again. Now, this is identifying an outcome for them. It's just a big fancy term for goal setting. So that is a little change of the nursing process that is that some nursing schools use. It's that O and add PI, which stands for outcome identification. So you are just identifying the outcome or the goal that your patient wants to achieve. And now let's talk about the next step of the nursing process. This is the P in adpie, which stands for planning. And planning just means that you are figuring out how the patient will achieve their goals. So these are really the nursing interventions that you will do as the nurse to make these goals happen and to help them achieve that for them. So if we have that same patient who is needing help walking after surgery, perhaps our planning section might look something like the nurse will educate the patient on the proper use of a walker, or the nurse will educate the patient on how to ambulate safely with supervision. All of this is part of that P and ADPy, or the planning step of the nursing process, planning out exactly what you will do as a nurse to help your patient reach their health goals. Now, the next step in the nursing process is implementation, which is the I in adpy. Now, this is where you actually do what you plan to do in the previous step. So so far you've assessed your patient, you've written the nursing diagnosis for your patient, you've worked with them on setting outcomes or goals, goals for themselves, and you have planned out what you are going to do as the nurse, what you're going to do about it to help make those goals happen. And now in this implementation phase, you are simply doing those interventions that you came up with in the planning phase. So in our example, you would show your patient how to use a walker and you would answer any questions that they might have about it, and then you would show them how to ambulate safely with supervision, going from perhaps a sitting position or laying down position to standing safely. So that is the implementation phase of the nursing process. It's all about making those interventions actually happen and doing them. And finally, the last step of the nursing process is evaluation. That E in adpy, it stands for evaluation, where you evaluate if the patient met their goals or not and what needs to be changed in order to help them meet their goals or what new goals should be created for them. This is basically the nursing assessment all over again. You're always evaluating your patient's progress, where they are in their recovery journey, and then what needs to be changed in the previous steps of your nursing process to then help them meet their goals. So the last step of the nursing process is that evaluation. This is just a reassessment of your patient to see really how much progress they're making and if anything needs to be change to that plan of care. And those are the steps of the nursing process. Add, pie, assessment, diagnosis, planning, implementation and evaluation. Now remember that little change as well about outcome identification. Now there's three ways that I can help you more in nursing fundamentals in nursing school, of course. Number one, download this free cheat sheet. Like we talked about earlier, it walks you through the nursing process step by step. So don't miss out on that. And then of course number two, head on over over to nursingsos.com and check out our nursing School boxes. They are filled, packed, filled with goodies and resources to help you gain confidence in nursing school and learn things faster and pass your exams. You're gonna love them. And of course, if you want me to really hold your hand throughout your nursing school journey, please don't miss out on joining the Nursing SOS Membership community. It is packed with with step by step nursing lectures to really help you understand everything faster, including a full nursing fundamentals course. Plus you will get access to our wonderful nurses so you can ask questions anytime if you ever get stuck and we are here to help. The links to all of those things are in the description box below. And of course, if you liked this video, be sure to hit that like button. Leave a comment below to let me know that you loved it and share it with a friend that might also need help with the nursing process and nursing fundamentals. And of course hit subscribe and click that notification bell so you never miss a video. And click on one of these videos right over here so you can keep rocking nursing school and as always, go become the nurse that God created only you to be. And I'll see you next time on the Nursing School Show. Take care. Bye bye.