Nursing Process & Infection Prevention and Control: Structured Study Notes

Nursing Process

Introduction to the Nursing Process

The nursing process is a systematic, deliberate, and cyclical problem-solving approach used to meet the health and nursing needs of patients. It consists of five interrelated steps: assessment, diagnosis, planning, implementation, and evaluation. Each step informs the next, creating a feedback loop that promotes effective patient care.

• Definition: The nursing process is a framework for providing individualized, goal-directed nursing care.

• Steps: Assessment, Diagnosis, Planning, Implementation, Evaluation (ADPIE).

• Example: A nurse uses the process to identify a patient's risk for infection, plan interventions, and evaluate outcomes.

Steps of the Nursing Process (ADPIE)

Step	Key Actions
Assessment	Gather information, ask questions, collect subjective and objective data.
Diagnosis	Identify problems, prioritize, determine nursing diagnosis, inform healthcare team.
Planning	Develop goals and desired outcomes, prioritize problems, create action plan.
Implementation	Carry out or delegate interventions, organize and manage patient care, educate patient.
Evaluation	Analyze and document patient responses, assess signs and symptoms, determine effectiveness.

Assessment

Collecting Data

Assessment involves systematically collecting data to establish a database about the client's response to health concerns. Data should be verified for accuracy and completeness.

• Subjective Data: Information reported by the patient (e.g., pain level).

• Objective Data: Observable and measurable facts (e.g., vital signs).

• Double-Checking: Verifying data to confirm accuracy.

Types of Assessments

• Initial: Comprehensive database, usually at admission.

• Focused: Assessment of a specific problem, takes minutes to hours.

• Emergency: Rapid assessment for new or life-threatening issues.

• Time-Lapsed: Reassessment at intervals (e.g., 3, 6, 9 months) to compare current status to baseline.

Nursing Diagnosis

Types of Nursing Diagnosis

• Actual: Problem present at the time of assessment.

• Risk: Problem does not exist, but risk factors are present.

• Wellness: Readiness for enhancement of health.

• Possible: Incomplete evidence about a health problem.

• Syndrome: Cluster of diagnoses that can be addressed through similar interventions.

Planning

Developing Goals and Outcomes

Planning involves determining how to prevent, resolve, or support identified priority client problems and strengths. Interventions should be organized, individualized, and goal-directed.

• Prevention: Strategies to avoid complications.

• Support: Enhancing client strengths.

• Implementation: Organizing interventions for best outcomes.

Guidelines for Writing Goal/Outcome Statements

• State in terms of client responses.

• Be realistic and compatible with other therapies.

• Derive from only one nursing diagnosis.

• Use observable, measurable terms.

Components of Goals/Desired Outcomes

Conditions/Modifiers	Criterion of Performance
2500 mL of fluid	daily (time)
correct insulin dose	using aseptic technique (accuracy indicator)
three hazards of smoking (after reading literature)	(accuracy indicator)
five symptoms of diabetes before discharge	(accuracy indicator)
the length of the hall without a cane	by date of discharge
less than 10 inches in circumference	in 48 hours (time)
leg ROM exercises as taught	every 8 hours (frequency)
foods high in salt from a prepared list	before discharge
the purposes of his medications	before discharge

Implementation

Carrying Out Interventions

Implementation is the process of carrying out or delegating and documenting planned nursing interventions. Without implementation, evaluation cannot occur.

• Assist client: Meet goals/outcomes.

• Promote wellness: Encourage healthy behaviors.

• Prevent illness: Reduce risk of disease.

• Restore health: Support recovery.

• Facilitate coping: Help with altered functioning.

Types of Nursing Interventions

• Direct: Performed through interaction with the client.

• Indirect: Performed away from but on behalf of the client.

• Independent: Initiated by the nurse.

• Dependent: Require orders from physicians.

• Collaborative: With other professionals.

Evaluation

Assessing Outcomes

Evaluation is a planned, ongoing activity to determine the client's progress toward achievement of goals and the effectiveness of nursing care.

• Collect data: Related to outcomes.

• Compare data: With expected outcomes.

• Relate activities: To client status.

• Draw conclusions: About status.

• Continue, modify, or terminate: The nursing care plan.

Additional info:

• These notes are foundational for both nursing and psychology students interested in health and well-being, especially in clinical and health psychology contexts.