Discussion about the nursing process and adpie

Nursing process

1. HEALTH ASSESSMENT

2. OVERVIEW OF NURSING PROCESS
Nurses apply the nursing process as a competency when
delivering patient care (Kataoka-Yahirp and Saylor, 1994). The
American Nurses Association (ANA) (2010) developed
standards that set forth the five-step nursing process:
ASSESSMENT, DIAGNOSIS, PLANNING, IMPLEMENTATION, AND
EVALUATION.

3. The Standard of Practice
The Standards of Practice describe a competent
level of nursing care. The levels of care are
demonstrated by a critical thinking model known
as the NURSING PROCESS: ADPIE

THIS IS THE FOUNDATION OF CLINICAL DECISION MAKING AND
INCLUDES ALL SIGNIFICANT ACTIONS TAKEN BY NURSES IN
PROVIDING CARE TO PATIENTS.

4. What is ADPIE?
Definition: ADPIE stands for Assessment, Diagnosis, Planning,
Implementation, and Evaluation.
Purpose: It’s a structured approach used by nurses to provide the
highest quality care to patients.
Why it matters: Ensures a thorough, holistic, and individualized
approach to patient care.

5. The Five Steps of ADPIE

1.ASSESSMENT
Collect data about the patient’s health status (physical, psychological, and social aspects).
2.DIAGNOSIS
Identify patient problems based on assessment data.
3.PLANNING
Develop a care plan with specific goals and interventions.
4.IMPLEMENTATION
Execute the care plan through nursing actions.
5.EVALUATION
Assess the effectiveness of the interventions and modify the plan as needed.

6. Types of Health Assessment


Initial/Comprehensive Assessment
●First assessment when a patient enters care.
●Involves a complete review of health history, physical examination, and lab tests.

Ongoing/Partial Assessment
●Conducted during the patient’s stay to track progress.

Focused/Problem Oriented Assessment
●Focuses on specific problems or concerns that have been identified.

7. Types of Health Assessment


Emergency Assessment
●Rapid assessment in critical situations to identify life-threatening issues.
●Prioritizes immediate interventions.

Time-lapsed Assessment
●Re-assessment after a period of time to evaluate changes in health status.
●Helps in monitoring recovery or the progression of a disease.

8. Assessment Methods
●Subjective Data: Information provided by the patient (e.g., symptoms, feelings).
●Objective Data: Observations or measurements made by the nurse (e.g., vitals, lab
results).
Health Assessment Tools
●Physical Examination: Inspection, palpation, percussion, auscultation.
●Patient History: Comprehensive review of past health conditions, surgeries,
medications.
●Diagnostic Tests: Blood tests, imaging, and other laboratory results.

9. ADPIE & Health Assessment Connection
●Assessment forms the foundation of ADPIE.
●Through effective health assessment, accurate diagnosis and tailored care
plans can be created.
●Evaluation relies on ongoing assessments to monitor progress and adjust
care as necessary.

10. INITIAL/COMPREHENSIVE ASSESSMENT
An Initial/Comprehensive Assessment is a thorough and detailed evaluation conducted when a patient first enters the healthcare
system, such as during an initial visit to a healthcare provider or hospital. This assessment is broad in scope and aims to gather
essential information about the patient's overall health and medical history.
Initial/Comprehensive Assessment:
●Purpose: To establish a complete baseline of the patient’s health status. This helps to identify potential health problems,
existing conditions, and risk factors.
●Scope: It covers all aspects of the patient's health, including physical, psychological, social, and emotional factors.
●Timing: Typically done at the beginning of a patient's care, when they first seek medical attention or when admitted to a
hospital.
Key Characteristics:
1.Holistic Evaluation: A comprehensive assessment includes a detailed health history, physical examination, and possibly lab
tests or imaging studies.
2.Baseline Data: The data collected forms a baseline against which future changes in the patient’s condition can be compared.
3.Establishing Rapport: This is also a time for the healthcare provider to build trust with the patient, establish communication,
and understand their concerns or goals for treatment.

11. Components of an Initial/Comprehensive Assessment:

1.Health History:
○Medical history: Past illnesses, surgeries, allergies, and treatments.
○Family history: Any hereditary health conditions.
○Medications: Current prescriptions, over-the-counter drugs, and supplements.
○Lifestyle: Smoking, alcohol use, exercise, diet, and sexual health.
2.Physical Examination:
○Vital signs: Temperature, blood pressure, heart rate, respiratory rate.
○Body systems examination: A detailed inspection of all body systems (e.g., cardiovascular, respiratory,
musculoskeletal).
3.Laboratory and Diagnostic Tests (if needed):
○Blood tests, urinalysis, imaging (X-rays, MRIs, etc.).
4.Psychosocial Assessment:
○Mental health status, stressors, social supports, and living conditions.

12. Example:
●Patient Admission: A patient admitted to the hospital with complaints of shortness of breath would undergo an
initial/comprehensive assessment that includes:
○Detailed health history (e.g., history of asthma, smoking).
○Physical exam (e.g., lung sounds, heart rate, oxygen saturation).
○Diagnostic tests (e.g., chest X-ray, blood tests, ECG).

Why it Matters:
●Informed Care: It provides a comprehensive view of the patient's health, allowing for an informed diagnosis and treatment plan.
●Foundation for Future Assessments: Establishes a baseline for ongoing and focused assessments.
●Prevention: Early identification of potential risks or health problems that might not be immediately apparent.

This type of assessment is critical for effective patient care, as it provides the nurse or healthcare provider with all the necessary
information to create a personalized, comprehensive care plan.

13. ONGOING/PARTIAL ASSESSMENT
An ongoing or partial assessment is a type of assessment that is conducted regularly throughout the course of patient care. It’s used to monitor
a patient’s progress, detect any changes in their condition, and update the care plan accordingly.
Ongoing or Partial Assessment:
●Purpose: To evaluate the patient's status and response to treatment over time. It helps in detecting changes or trends in the patient’s
health condition.
●Scope: This assessment focuses on specific issues identified during the initial or comprehensive assessment and continues to monitor
them. It does not involve a full reassessment of the entire body or all systems.
●Timing: Conducted at regular intervals, such as during each nursing shift or at scheduled follow-up appointments.
Key Characteristics:
1.Continuous Monitoring: Often used for patients with chronic conditions, acute illnesses, or those recovering from surgery. It provides
ongoing data about how well the patient is responding to treatment.
2.Faster and Targeted: Focuses on issues or areas that need follow-up, rather than starting from scratch with a full assessment each time.
3.Dynamic Process: The findings from an ongoing assessment guide adjustments to the care plan.

14. Example:
●Post-Surgery Patient: After a patient undergoes surgery, an ongoing assessment would track things like:
○Vital signs (temperature, pulse, respiratory rate).
○Surgical site for signs of infection or healing.
○Pain levels and any changes.
●Chronic Condition: For a patient with diabetes, an ongoing assessment might focus on:
○Blood glucose levels.
○Skin integrity, especially in areas prone to ulcers.
○Any signs of complications like neuropathy.

Why it Matters:
●Early Detection: Helps in identifying any deterioration or improvement early, allowing for timely interventions.
●Adjusting Care Plans: Helps healthcare providers make necessary adjustments to the treatment plan based on the patient's current
status.

15. FOCUSED/PROBLEM ORIENTED ASSESSMENT
A focused or problem-oriented assessment is a type of health assessment that is concentrated on a specific issue or problem that the patient is experiencing. Unlike a
comprehensive assessment, which looks at the overall health of the patient, a focused assessment targets a particular concern or symptom that has been identified.
Here’s a breakdown of its key points:
Focused or Problem-Oriented Assessment:
● Purpose: To gather more detailed information about a specific issue or problem the patient is facing.
● Scope: It focuses on one or more specific health concerns (e.g., a cough, pain, or shortness of breath).
● Timing: Often performed when a new concern arises, or during follow-up visits to monitor progress on a specific problem.
Example:
● A patient comes in with chest pain. A focused assessment would concentrate on the chest pain, asking questions like:
○ When did the pain start?
○ Is it sharp, dull, or aching?
○ Does it radiate to other parts of the body (like the left arm or jaw)?
○ What makes the pain better or worse?
● Based on this, the nurse may take vital signs, assess the heart and lung sounds, and possibly order diagnostic tests.

16. Key Characteristics:
1.Narrow Scope: Targets only the identified problem.
2.Efficiency: It’s quick and efficient for addressing specific concerns.
3.Follow-up: It’s often used for ongoing conditions, post-operative care, or when symptoms evolve.

This type of assessment helps nurses and healthcare professionals focus their care and interventions effectively

17. EMERGENCY ASSESSMENT
An Emergency Assessment is a rapid and focused evaluation performed in urgent or life-threatening situations to identify and
prioritize immediate health concerns. The goal is to quickly determine the patient's condition and take action to stabilize them.
Emergency Assessment:
●Purpose: To quickly identify and address life-threatening issues, ensuring the patient's immediate survival and stabilization.
●Scope: The assessment is narrow and prioritizes the most critical areas of concern that could endanger the patient’s life.
●Timing: It occurs during an emergency situation, such as in the emergency room (ER), during an accident, or when a patient
exhibits acute, severe symptoms.
Key Characteristics:
1.Rapid Evaluation: Time is a critical factor in emergency assessments. The focus is on gathering key data quickly to make
immediate decisions.
2.Prioritization: The assessment prioritizes ABC (Airway, Breathing, Circulation) to address the most critical needs first.
3.Focused: It’s not a comprehensive or thorough assessment but rather a focused evaluation of the immediate issue that
requires attention.

18. Steps in Emergency Assessment:
1.Airway:
○Check if the patient’s airway is clear and open.
○Any obstruction to the airway needs to be cleared immediately.
2.Breathing:
○Assess the patient’s breathing: Are they breathing adequately? What is their respiratory rate? Are there signs of distress
like labored breathing or cyanosis (bluish skin)?
3.Circulation:
○Check the patient’s pulse, blood pressure, and skin condition (e.g., signs of shock, pallor, or cool extremities).
○Ensure that there is adequate blood flow to vital organs.
4.Disability (Neurological):
○Quickly assess the patient’s neurological status (e.g., level of consciousness, pupil response, limb movement).
5.Exposure:
○Assess the patient's body for any other life-threatening injuries (e.g., bleeding, burns, fractures).

19. Example:
●Car Accident: A patient brought to the emergency room after a car accident would undergo an emergency assessment that
focuses on:
○Ensuring the airway is open and breathing is supported.
○Checking for severe bleeding or signs of shock (circulation).
○Quickly assessing for any head or spinal injuries, loss of consciousness, or neurological deficits (disability).
○Identifying fractures or internal injuries that need immediate care.

Why it Matters:
●Quick Decision-Making: It allows healthcare professionals to quickly identify critical conditions and provide timely
interventions.
●Prevent Further Harm: The rapid nature of this assessment prevents further harm by addressing the most urgent concerns
first.
●Life-Saving: It’s a key component of saving lives, especially in trauma, severe illness, or accidents.

20. This type of assessment is essential in ensuring the patient's survival in
emergency situations. It provides a foundation for immediate intervention and sets
the stage for further, more detailed assessments once the patient’s life-threatening
issues are stabilized.

21. TIME-LAPSED ASSESSMENT
A Time-lapsed Assessment is a follow-up evaluation conducted after a certain period to assess changes in a patient’s health status over time. It
allows healthcare providers to track the progress of a patient’s condition, recovery, or response to treatments, and make necessary adjustments to
the care plan.
Time-lapsed Assessment:
●Purpose: To evaluate how a patient’s condition has changed over time, such as after treatment or during recovery from illness or surgery.
●Scope: This assessment focuses on specific health issues that need monitoring and reassessment, rather than performing a complete
physical exam.
●Timing: It is done at scheduled intervals, often after a set period, to monitor progress and detect any new concerns.
Key Characteristics:
1.Follow-up: It’s performed after the initial or comprehensive assessment to monitor how a patient's condition evolves or responds to
treatment.
2.Tracking Changes: The assessment helps identify improvements, complications, or deteriorations in the patient’s health.
3.Adjustment to Care Plan: Based on the findings, the care plan can be adjusted to ensure optimal outcomes.

22. Example:
●Post-Surgery: A patient who underwent surgery might have a time-lapsed assessment to evaluate:
○Wound healing and the absence of infection.
○Pain levels and whether the pain management plan needs adjusting.
○Mobility and the need for physical therapy or rehabilitation.
●Chronic Condition (e.g., Diabetes): A patient with diabetes might undergo time-lapsed assessments to track:
○Blood glucose levels over weeks or months.
○Changes in weight, diet, or activity levels.
○Early signs of complications such as neuropathy or retinopathy.

23. Why it Matters:
●Track Progress: It provides insight into whether a patient is improving, staying the same, or experiencing a decline.
●Timely Interventions: Identifying issues early allows for adjustments to the care plan to prevent further complications.
●Monitor Effectiveness: Helps in evaluating the success of treatments or interventions over time.

A Time-lapsed Assessment is especially valuable for chronic conditions, post-operative recovery, and ongoing treatment monitoring. It
provides healthcare providers with the necessary data to adjust care plans and ensure the best possible outcome for the patient.