Show Menu

Nursing Process 101 - ADPIE Cheat Sheet by

Nursing process - ADPIE


Systematic guide to patien­t-c­entered care
  > involves critical thinking skills and data collection

1. Assessment
2. Diagno­sis­/An­alysis
3. Planning
4. Implem­ent­ation
5. Evaluation
*although the steps are ordered, nursing is not linear and care is both cyclic and bidire­ctional

DOCUMENT! DOCUMENT! DOCUMENT! If it wasn't docume­nted, it wasn't done


first function of the nurse: data collection and docume­ntation
explore the pt's viewpoint
  > interview, physical examin­ation, observ­ation, functional assessment
  > initial, focused, organized, emergent
  > collect subjective & o­bje­­ctive data
  > pt demogr­aphics, past medical history, past surgical history
  > utilize database: patient medical records, labs and diagnostic results
  > gather info about pt's condition HPI, cc, vital signs and/or lab results
  > compre­hensive ROS review of systems
  > risk assess­ment: identify any potential health problems
  > inquire about related goals, experi­­ences, values & expect­­ation about healthcare system
  > cluster cues and data, make inferences & identify patterns & problems
  > must be: purpos­­eful, priori­­tized, complete, system­­atic, factual, relevant, documented
collect, analyze, validate, commun­­icate


Nursing diagnosis vs medical diagnosis
  > nursing diagnosis is human response to illness; unique to each patient
Use clinical judgement and analyze data; actual vs potential health problem, wellness
clarify exact nature of problem or risk to achieve overall outcome
> Identify how pt responds to health or life processes
> Identify factors contri­butes to problem; specific, critical and related
> Identify resources & strengths of pt
health problem prevented or resolved
> problem focused (actual)
> identify "at risk for" problems
> health promotion (wellness)
  - problem NANDA
  - etiology "­related to" or "­r/t­"
  - symptoms "as evidenced by" or "­AEB­"
*use nursing standards to help determine nursing diagnosis
One-part (diagn­osis), two-part (diagnosis + etiology) and three-part statements (diagnosis + etiology + s/s)


Plan of care
Design of plan of care results in preven­tion, reduction, resolution of pt health problems
  > Priori­ties: high, interm­ediate, low
  > MASLOW: physio­log­ical, safety, love/b­elo­nging, esteem, self actual­ization
  > SMART goals: Specific, Measur­able, Attain­able, Realistic, Timed
  > Short-term and long term
1. establish priorities and develop outcomes
  - indivi­dua­lized
  - culturally approp­riate
2. identify and document expected outcomes
3. identify and select nursing interv­ent­ions: integrate EBP and nursing standards
4. commun­icate and document care plan

Identify expected outcomes and goals and criteria for success related to the pt's needs


Implement the plan of care, nursing interv­ention actions
Specify the nursing actions and interv­ent­ions, who, what, when, how
> plans are carried out, safely and timely
> plans are evidence based
> coordinate care delivery
> provide health teaching and health promotion
> document implem­ent­ation and any modifi­cations

indepe­ndent, dependent, and collab­ora­tiv­e/i­nte­rde­pendent
  - indepe­ndent: nurse initiated, w/o MD orders
  - dependent: MD orders (all medica­tions)
  - interd­epe­ndent: PT, OT, social worker, RT, dietician

direct and indirect
  - direct: intera­ction with the patient (ie. v/s, medication admini­str­ation)
  - indirect: no intera­ction with the patient (ie. speaking with MD, creating plan of care)

Implem­ent­ation (cont.)

manage and collab­oration
physical care
commun­icate nursing interv­ention
lifesaving measures
pt teaching and education
medication admini­str­ation; monitor for adverse effects


Re-ass­essment of how well pt has achieved expected therap­eutic outcomes
  ongoing through nursing process

> resolve health problems
> prevent potent­ially new problems
> collect data
> maintain a healthy state/ health promotion
> document findings using clinical judgement
> terminate, continue, modify
> goals met, partially met, unmet

*Include the pt and their family by interp­reting and summar­izing findings
if the goal(s) has not been met, reasse­ssment and revision of plan of care




No comments yet. Add yours below!

Add a Comment

Your Comment

Please enter your name.

    Please enter your email address

      Please enter your Comment.

          Related Cheat Sheets

          FREQUENTLY USED DX CODES Cheat Sheet
          Paediatric Respiratory Assessment Cheat Sheet

          More Cheat Sheets by NursingStudent3267