Nursing Process
Key Points
- The nursing process is a cyclical framework for clinical reasoning and consistent care delivery.
- ADOPIE stands for Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.
- Nursing assistants are essential in implementation support and real-time reporting during evaluation.
Pathophysiology
The nursing process is a care-systems model, not a disease pathophysiology. It structures how data are collected, interpreted, and translated into individualized interventions with measurable outcomes.
When used consistently, it reduces omissions and duplication, improves continuity across shifts, and strengthens safety. CNA observations become high-value inputs that influence reassessment and care-plan updates.
Classification
- Assessment: Comprehensive data collection across physical and psychosocial domains.
- Diagnosis/Outcomes: RN clinical judgment and measurable goal setting.
- Planning/Implementation: Evidence-based interventions, delegation, and care-plan execution.
- Evaluation: Ongoing comparison of outcomes to baseline and intervention effectiveness.
Nursing Assessment
NCLEX Focus
Priority questions ask which observations from CNA care should be escalated as meaningful data in the nursing process.
- Observe and report changes in skin integrity, pain, cognition, edema, mobility, intake/output, and behavior.
- Confirm delegated interventions are understood and feasible in current context.
- Identify when planned interventions are ineffective and require RN reassessment.
- Report new safety concerns promptly to support timely plan modification.
Nursing Interventions
- Review care plan before tasks and follow delegated steps exactly.
- Implement interventions safely and document completion in real time.
- Communicate objective resident responses to interventions.
- Escalate ineffective or unsafe interventions immediately to nurse supervisor.
Delegation and Safety Risk
Performing interventions without clear delegation, supervision, or feedback can cause patient harm and disrupt care continuity.
Pharmacology
| Drug Class | Examples | Key Nursing Considerations |
|---|---|---|
| medication-regimen-management | RN-administered contexts | CNA monitoring/reporting of response and side effects supports evaluation phase. |
| high-alert-medications | Safety-critical contexts | Prompt observation reporting helps prevent escalation of adverse events. |
Clinical Judgment Application
Clinical Scenario
A resident’s edema and fatigue worsen after a newly implemented activity plan.
Recognize Cues: Objective deterioration despite planned intervention. Analyze Cues: Current plan may be mismatched to tolerance and needs reassessment. Prioritize Hypotheses: Immediate priority is RN evaluation and intervention adjustment. Generate Solutions: Document trend, report findings, and reduce strain-provoking activities pending guidance. Take Action: Communicate promptly using objective observations and timing. Evaluate Outcomes: Updated care plan improves tolerance and safety.
Related Concepts
- scope-of-practice - Clarifies which nursing-process activities can be delegated.
- documenting-and-reporting-data - Accurate records are core to evaluation and continuity.
- communication-within-the-health-care-team - Team coordination operationalizes care plans.
- ethical-and-legal-responsibilities-of-the-nursing-assistant - Legal practice boundaries apply to implementation.
- members-of-the-health-care-team-and-nursing-home-structure - Interdisciplinary roles support each phase.
Self-Check
- Which CNA observations most strongly influence reassessment and care-plan changes?
- Why is implementation documentation essential in the evaluation phase?
- When should a delegated intervention be paused and escalated?