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Nursing Process 101 - ADPIE Cheat Sheet (DRAFT) by

Nursing process - ADPIE

This is a draft cheat sheet. It is a work in progress and is not finished yet.

NURSING PROCESS

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

Assessment

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, vital signs and/or lab results
  > risk assess­ment: identify any potential health problems
  > inquire about related goals, experi­­ences, values & expect­­ation about healthcare system
  > cluster cues, make inferences & identify patterns & problems
  > must be: purpos­­eful, priori­­tized, complete, system­­atic, factual, relevant, documented
collect, analyze, validate, commun­­icate

Diagnosis

Use clinical judgement; actual vs potential health problem
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
  - problem NANDA
  - etiology "­related to"
  - symptoms "as evidenced by"
*use nursing standards to help determine nursing diagnosis

Planning

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
Steps
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 goals and criteria for success related to the pt's needs
 

Implem­ent­ation

Implement the plan of care
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

Implem­ent­ation (cont.)

Direct
Indirect
ADLS
manage and collab­oration
physical care
commun­icate nursing interv­ention
lifesaving measures
delegating
counseling
superv­ising
pt teaching and education
evaluating
prevention
medication admini­str­ation; monitor for adverse effects

Evaluation

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

*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

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