Nursing Process (ADPIE)
Assessment *Frequency varies with health needs*
o Subjective Data: What the patient is SPEAKING
o Objective Data: What you
... [Show More] are OBSERVING
Observation of patient behavior (verbal vs. nonverbal)
o Collection of Data
Review of clinical record
Interview
Health history
Physical examination
Functional assessment
Cultural and spiritual assessment
Consultation
Review of the literature
Diagnosis
o Form a diagnostic conclusion.
o Clinical judgement about patient. “Impaired gas exchange”
o PES Format
P= Problem, use NANDA-I label
E= Etiology or related factor
S= Symptoms or defining characteristics
Example: Impaired comfort r/t left ankle sprain AEB (As Evidenced By)
patient verbalizes pain 9/10 on pain scale
Planning
o Setting Priorities.
ABCS: Airway, Breathing, Circulation, Safety
Maslow’s
Classification of priorities:
High—Emergent…Airway Issues
Intermediate… Pain
Low—Affect patients’ future well-being
o Identifying patient goals
SMART:
Specific
Measurable: can observe
Attainable: nurse and client mutual understanding
Realistic
Timed: short term/long term
o Nursing interventions
Independent: Actions that a nurse can initiate without order
Dependent: Require an order from a physician or other health care
professional
Collaborative: Team interventions.. Doctor, PT/OT, Dietitian,
Plan of care changes as the patient’s need change.
Implementation
o Treatment nurse performs to enhance patient outcomes.
o Educate the person and significant others
o 5 Steps
Reassess the patient
Revise the nursing care plan
Organize resources and care delivery
Anticipate and prevent complications
Implement nursing interventions
Evaluation
o Were goals met?
o Do we need the plan of care?
o Restart nursing process if goals not met.
Critical Thinking Principles
• Proceed through sequential steps from novice to expert
o Incorporation of experience provides foundation for development of clinical
practice
• Utilize a multidimensional thinking approach to interpret data
o Use an organized, systematic assessment format
• Validate and confirm findings based on nonjudgmental interpretation of data
o Check and corroborate accuracy and reliability of data
• Cluster data information to support evidence as well as rule out inconsistent clinical
findings in terms of differential diagnosis
o Distinguish relevant signs and symptoms
Priority Problem Level
• First-level priority
o Emergent, life threatening, and immediate
o ABCs
o Life threatening Vital Sign and Labs
• Second-level priority
o Next in urgency, requiring attention to avoid further deterioration
o Change in mental status, pain, urinary issues, untreated med issues
• Third-level priority
o Important to patient’s health but can be addressed after more urgent
problems are addressed
o Activity, education
• Collaborative problems
o Approach to treatment involves multiple disciplines
Holistic Model of Health
• Mind, body and spirit are interdependent and function as a whole
• Assess factors such as lifestyle behaviors, culture and values, family and social roles,
self-care behaviors, job-related stress, developmental tasks, failures and frustrations of
life
• Health promotion and disease prevention form the core of nursing
• MUST include culture
Cultural Assessment
What to consider with Cultural Competency?
• Health Literacy patient has
• What is their cultural background?
o Will their beliefs “interfere” with health care?
• Any language barriers?
o Should have on staff interpreter
• Financial status
• Health Disparities
Characteristics of Cultural Competency
• Culturally sensitive
o Possessing basic knowledge of and constructive attitudes toward diverse cultural
populations
• Culturally appropriate
o Applying underlying background knowledge necessary to provide the best
possible health care
• Culturally competent
o Understanding and attending to total context of patient’s situation including the
following:
Immigration status
Stress and social factors
Cultural similarities and differences
Socialization
• Process of being raised within a culture and acquiring characteristics of that group
o Acculturation: process of adapting to another culture
o Assimilation: process of developing a new cultural identity and becoming like
members of dominant culture
o Biculturalism: dual pattern of identification and often of divided loyalty
Expression of pain
• Silent suffering has been identified as the most valued response to pain by health care
professionals
The Interview
Interview Process
• Interview is the first step in the therapeutic relationship
• Introduction of yourself
• Purpose of interview
• Duration
• Expectation of participation for each person
• HIPPA
• Verbal and nonverbal cues we send and receive with the patient
o Body language
o Make eye contact
o Assess how patient reacts when speaking
• Question Type
o Open ended or Closed ended questions
Types of Verbal Responses
• Silent attentiveness
o Gives patient time to think and organize thoughts
o Gives you a chance to observe person unobtrusively and note nonverbal cues
• Reflection
o Repeating what person has just said
o Focuses attention on certain point of conversation
• Empathy
o Recognizes a feeling and puts it into words
• Clarification
o Used to summarize person’s words and to simplify them to make them clearer
• Confrontation
o You have observed a certain action, feeling, or statement and now focus person’s
attention on it
• Interpretation
o Based on your inference or conclusion
• Explanation
o Sharing factual and objective information, offering reasons for requirements or
actions
• Summary
o Final review of what person has said; it condenses facts and presents your view of
health problem [Show Less]