Nursing Process (ADPIE) recopied from the original author of this ppt jeena.aejy

The Nursing Process (ADPIE).

1. NURSING

PROCESS
Presented by: Dave Jay S. Manriquez RN.

2. THE NURSING
PROCESS
A systematic problem-solving
approach used to identify, prevent
and treat actual or potential health
problems and promote wellness.

3. Nursing process
A systematic way to plan,
implement and evaluate care for
individuals, families, groups and
communities.

4. Characteristics of the
Nursing Process
Dynamic
Client-centered
Planned
Interpersonal and collaborative
Universally applicable
Can focus on problems or strengths

5. Open, flexible
 Humanistic and individualized
 Cyclical
 Outcome focused ( results oriented)
 Emphasizes feedback and validation

6. STEPS IN NURSING PROCESS
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation

7. AssessmentAssessment
Nursing Nursing
DiagnosisDiagnosis
PlanningPlanning
ImplementationImplementation
EvaluationEvaluation
Nursing Nursing
ProcessProcess

8. Benefits of using the nursing
process
Continuity of care
Prevention of duplication
Individualized care
Standards of care
Increased client participation
Collaboration of care

9. EVALUATION
IMPLIMENTA
TION
PLANNING
ASSESSMENT
DIAGNOSIS
INTER RELATIONSHIP BETWEEN THE STEPS OF NURSING PROCESS

11. ASSESSMENT

12. Assessment
Assessing is a continuous process carried out
during all phases of nursing process. All
phases of the nursing process depend on the
accurate and complete collection of data.
Assessing is the systematic and continuous
collection, organization, validation and
documentation of data.
- Potter and Perry( 2006)

13. Assessment is the deliberate and systematic
collection of data to determine a clients current and
past health status and to determine the clients
present and past coping patterns
- Carpenito 2000

Assessment is the systematic and continuous
collection, validation and communication of patient
data.
- Carol Taylor

14. Types of Assessment
1. Initial Assessment: Performed within specified time after admission to a health
care agency

Eg. Nursing Admission Assessment

2. Problem Focused Assessment: Ongoing process integrated with nursing care to
determine specific problem identified in an earlier assessment and to identify new or
overlooked problems.

E.g.. Assessment of clients ability to perform self-care while assisting client to bathe.


3. Emergency Assessment: Done during psychiatric or physiological crisis of the
client to identify life threatening problems

Eg. Rapid assessment of airway, breathing and circulation during cardiac arrest

4. Time lapsed-Reassessment: Done several months after initial assessment to
compare the clients status to baseline data previously obtained.

15. Assessment
ASESSMENT
Collect data
Organize data
Validates Data
Document data
DIAGNOSIS
PLANNING
IMPLIMENTAT
ION
EVALUATION

16. 1.COLLECTION OF DATA
Data Collection is the process of gathering
information about a clients health status.

17. Collection of Data:

Data base: A data base is all information about a
client. It includes the nursing health history,
physical assessment, the physician’s history,
physical examination, results of laboratory and
diagnostic tests and material contributed by
other health personnel.

18. Medical vs. Nursing
Assessments
Medical assessments
Target data pointing to pathologic conditions
Nursing assessments
Focus on the patient’s response to health
problems

19. Types of Data:
 
SUBJECTIVE DATA: Also referred to as symptoms or covert data
are apparent only to the person affected and can be described
or verified only by that person

Eg. Itching, Pain, Feelings of worry
OBJECTIVE DATA: Also referred to as signs or overt data. These
are detectable by an observer or can be measured or tested
against an accepted standard.

They can be seen, heard, felt or smelled and they are obtained
by observation or physical examination

Eg. A Blood Pressure Data
Discolouration of the Skin

20. Objective Data vs.
Subjective Data
Objective data
Observable and measurable data that can be seen,
heard, or felt by someone other than the person
experiencing them
E.g., elevated temperature, skin moisture, vomiting
Subjective data
Information perceived only by the affected person
E.g., pain experience, feeling dizzy, feeling anxious

21. Sources of Data:
Primary Source (Direct
Source
client: Usually BEST source

22. Secondary Source (Indirect
Source)
Family Members
 Client’s records
1. Medical Records
Eg. Medical History, Physical Examination,
Operation notes, Progress notes,
Consultation done by Physicians
2. Records of therapies done by other health professionals
Eg. Social Workers, Dieticians, Physical Therapist
3. Laboratory Records
 Other health care professionals Verbal reports
Literature

23. Data Collection
Consider
time
needs of patient
developmental stage
physical surroundings
past and present coping patterns

24. Data Characteristics
Complete
Factual
Accurate
Relevant

25. Data collection methods
OBSERVATION
INTERVIEWING
PHYSICAL ASSESSMENT

26. Observation
To gather data using senses
Eg: laboured breathing, pallor or flushing,pain
a lowered side rail ,functioning of an equipment ,
pt environment and people in it etc…

27. Interviewing
An interview is a
planned
communication or
a conversation with
a purpose
Types of questions
and
Setting
Rapport are
important
Collection of
Health History

28. Four Phases of a Nursing
Interview
Preparatory phase
Introduction
Working phase
Termination

29. Interview Phases
Preparatory
Nurse collects background info from
previous charts
Ensure environment is conducive
Arrange seating
3 – 4 ft apart
Interviewer at 45° angle to patient
Allow adequate time

30. Phases cont’d.
Introduction
Nurse introduces self
Identifies purpose of interview
Ensure confidentiality of
information
Provide for patient needs before
starting

31. Phases cont’d.
Working
Nurse gathers info for subjective data
Excellent communication skills are
needed
Active listening
Eye contact
Open-ended questions

32. Phases cont’d.
Termination
Inform patient when nearing end of
interview
Ensure patient knows what will
happen with info
Offer patient chance to add
anything

33. Physical assessment
Appraisal of health
status
Usually by Review of
Systems
Overview of
symptoms
Observable,
measurable data

34. Objective data
Possible approaches—body systems, head to
toe, or functional health patterns

35. Methods of physical
assessment
Inspection
Percussion
Palpation
Auscultation

36. Problems Related to Data
Collection
Inappropriate organization of the database
Omission of pertinent data
Inclusion of irrelevant or duplicate data,
erroneous or misinterpreted data
Failure to establish rapport and partnership
Recording an interpretation of data rather than
observed behavior
Failure to update the database

37. 2.ORGANISING DATA
Nurses uses a
written or
computerized
format for
arranging he data
systematically

38. 3.VALIDATING DATA
 VALIDATING -THE ACT OF DOUBLE
CHECKING
Verifies understanding of information
Comparison with another source
-patient or family member
-record
-health team member

39. 4. DOCUMENTING DATA
Record in permanent record ASAP
Use patient’s own words in subjective
data – enclose in “ ___” (quotation
marks)
Avoid generalizations – be specific
Don’t make summative statements

40. Thank you