Nursing Process Applied to Older Adults in Care Transition From Hospital to Home: A Scoping Review

Introduction: The hospital-to-home care transition poses significant challenges for older adults due to factors such as physical/cognitive decline, limited support, low health literacy, socioeconomic barriers, and poor care coordination. These challenges include readaptation to daily life and negative feelings such as uncertainty, worry, loneliness, and fear of dealing with adverse events at home. A tailored nursing process can potentially improve this transition. This scoping review mapped evidence on the nursing process for older adults during hospital-to-home transitions. Method: A scoping review following Joanna Briggs Institute methodology was conducted. Searches included Embase, Lilacs, Livivo, PubMed, Scopus, Web of Science, and gray literature sources (Google Scholar, CAPES Catalog), performed in 2023 and updated in March 2025. Eligible sources (original articles, reports, theses/dissertations) addressed nursing process development for this transition. Evidence was synthesized using descriptive analysis. Results: Eleven sources were included. Six (54.5%) used nursing taxonomies, primarily NANDA-I (five sources, 45.4%). Two sources (18.2%) used theoretical frameworks (Self-Regulation Theory, Gottlieb's Strength-Based Care Theory). Six sources (54.5%) used instruments assessing demographics, function (cognitive, physical, mental), dependencies, adherence, self-management, caregiver readiness, and discharge/learning needs. Five sources (45.4%) listed 54 diagnoses, primarily related to safety/protection, activity/rest, and elimination/exchange domains. Two sources (18.2%) used nursing outcomes classification taxonomy for outcome planning. Interventions focused mainly on health education. A gap regarding the implementation phase was noted. Four sources (36.4%) addressed evaluation. Conclusion: These findings can guide clinical nurses in developing the nursing process for older adults transitioning home. The review identifies population needs, common assessment tools, frequent diagnoses/interventions, and evaluation methods, aiding nurses in tailoring care during this critical transition.