Nursing process: Clinical decision making

The nursing process is an iterative framework used by nurses to identify actual and potential patient issues, create and implement plans of care, and evaluate responses to care. Following the steps of the nursing process is integral for exercising clinical judgment and making informed clinical decisions. The nursing process allows nurses to successfully navigate patient needs within various clinical scenarios and is essential for providing safe, quality care and improving patient outcomes.

So, there are several versions of the nursing process, each represented by an acronym representing the steps. Perhaps the most well-known version is ADPIE which is a five-step process that includes assessment, diagnosis, planning, implementation, and evaluation. There’s also a six-step process, ADOPIE, which adds an O for outcome identification. Lastly, a shorter version is APIE, where the diagnosis step is integrated within assessment instead of standing on its own.

Okay, let’s take a closer look at each version. Starting with ADPIE, A stands for assessment which refers to the objective and subjective information the nurse gathers about a patient. Subjective data includes verbal statements from the patient or the primary caregiver regarding their current condition, past medical history, and medications; whereas objective data refers to measurable information, like vital signs and laboratory results.

Next, D is for diagnosis, where the nurse analyzes the previously collected assessment data to identify and define the patient's most pressing health problems and needs, which are often called “nursing diagnoses.” These diagnoses will guide the steps taken to address problems during step P or planning.

During planning, the nurse formulates patient-centered goals and develops interventions that will address the diagnosed problem and guide the plan of care.

The plan of care is then carried out during step I, or implementation, where the nurse and health care team members execute the interventions aimed at meeting the identified goals.

Lastly, E is for evaluation, which involves assessing the effectiveness of the interventions and modifying the care plan as needed. For instance, if the nurse notices that the patient’s condition hasn't improved or if new issues are discovered during reassessment, the nursing process starts over from the beginning.

Moving on to ADOPIE, this process includes an additional step called outcome identification between diagnosis and planning. While outcome identification, also called goal setting, is typically part of the planning stage in ADPIE, ADOPIE offers this as a separate step dedicated to establishing clear outcomes before planning interventions. These outcomes or goals should be specific, measurable, achievable, relevant, and time-bound, or SMART for short, to ensure that planning is structured and patient-centered.

Finally, in APIE, the diagnosis step is integrated into the assessment phase. Although diagnosis isn’t singled out, the nurse must still organize and analyze the collected data to identify the most pressing patient issues to guide interventions. The relevance of traditional nursing diagnosis language in clinical practice is a topic of debate; however, the process of identifying and describing patient problems continues to play a valuable role in supporting clinical judgment and guiding clinical decision-making.

Now let’s look at a scenario where a nurse uses the APIE version of the nursing process to make decisions and prioritize care.