Nursing Process: ADPIE & Assessment

Nursing Process

• Assessment, Diagnosis, Planning, Intervention, Evaluation (ADPIE) make up the nursing process
• Re-ADPIE is only used if the goal is unmet after the initial evaluation

Nurse-Patient Relationship

• Communication and trust are important values in the nurse-patient relationship

Assessment - Data Collection

• Assessment involves collecting, validating, and clustering data
• It is the first and most important step, identifying strengths and limitations
• Assessment is performed continuously, not just once

Purposes of Assessment

• Collects data pertinent to the patient's health status
• Identifies deviations from normal
• Discovers patient strengths and coping resources
• Pinpoints actual problems
• Spots factors that place patients at risk for health problems

Types of Assessment

• Comprehensive: examines overall health status (e.g., general check-up)
• Focused: monitors and evaluates the progress of an intervention (e.g., specialized check-up)
• Follow Up: evaluates the status of any identified problems
• Emergency: rapid collection of crucial information, concurrent with lifesaving measures and requires a swift and sure diagnosis

Medical vs Nursing Assessment

• Medical assessment focuses on the client's disease
• The goal is to cure the disease
• Physician orders interventions, nurses follow these orders
• Nursing assessment focuses on the client's response to the disease
• The goal is to direct the nursing plan of care to meet the patients' needs

Nursing Diagnosis

• The nursing diagnosis involves identifying and prioritizing actual or potential health problems or responses
• After identifying the diagnosis, it is important to prioritize them in order to develop a care plan

Purposes of Diagnosis

• Identifies nursing priorities
• Directs nursing interventions
• Provides a common language among healthcare team
• Gives a basis for evaluating if the nursing care was useful and cost-effective

Types of Nursing Diagnosis

• Actual diagnosis: occurring health problem (naan a), problem-focused diagnosis, presence of associated signs and symptoms, problem at the time of assessment
• Risk diagnosis: potential health problem, clinical judgements that a problem does not exist, risk factor exists and problem is likely to develop unless there is intervention
• Wellness diagnosis: possibility, needs more data to support it, statement that identifies the patient's readiness for engaging in activities, health promotion diagnosis, increase wellbeing
• Syndrome diagnosis: collaborative effort where needs both medical and nursing intervention

Planning

• involves setting goals and outcomes
• two components of a SMART plan
• Formulation of measurable outcomes
• Tailor-fitting nursing intervention
• Specific: details what exactly needs to be done
• Measurable: achievement or progress can be measured
• Achievable: a realistic objective that is likely to be achieved
• Realistic: objective is possible to attain
• Timed: time period for achievement is clearly stated

Implementation

• Also called an intervention
• Carrying out plan to achieve goals and outcomes

Evaluation

• Determining the effectiveness of your plan
• Goal met
• Partially met
• Not met

Patient Data

• Data for evaluation can be subjective or objective
• Subjective: the statement that the patient expresses through symptoms, sensations, or feelings perceived only by the affected person
• Objective: something measurable by standard medical devices that is overt and observed, a sign

Sources of Patient Data

• Primary: subjective or objective data coming directly from the patient
• Secondary: anyone or anything aside from the patient like family members, or medical records

Client Interview and Health History

• Data collection takes place through observation and interviews

Types of Interviews

• Direct: nurse directs and controls the interview, uses close-ended questions
• Non-directive: nurse clarifies and summarizes and uses open-ended questions

Importance of Client Interviews

• Gathers complete and accurate data about a person's health state and any symptoms
• Establishes trust so that the person feels accepted and thus free to share all relevant data
• Teaches the person about his or her health state
• Builds rapport for a continuing therapeutic relationship
• Discusses health promotion and disease prevention

Effective Verbal Communication

• Brevity, Clarity, Simplicity, and Timing and Relevancy

Active Listening

• Avoid interruptions and concentrate on the speaker
• Maintain eye contact if culturally appropriate
• Lean toward and face the speaker
• Maintain open posture, not crossed arms
• Make a conscious effort to hear and understand the other person; avoid premature interpretations and judgements
• Avoid extensive note taking

Non-Verbal Communication

• Includes body language, facial expressions, eye contact, gestures, posture, qualities of voice, physical appearance, touch, and silence

Guidelines for Use of Touch

• Generally is best to avoid, especially invasive procedures, until nurse-client relationship well-established and nurse attuned to beliefs about touch
• Should be used only by people of the same gender and culture
• A gentle touch nurse's hand on client's upper arm or shoulder could be used when a nursing history becomes too emotional

Functional Use of Space

• Intimate Zone (0 to 1 1/2 ft): Visual distortion occurs and is best for assessing breath and body odor
• Personal Distance (1 1/2 to 4 ft): Perceived as an extension of the self, similar to a bubble, with moderate voice and is without body odor
• Social Distance (4 to 12 ft): Use for impersonal business transaction, where perception is much less detailed
• Public Distance (12+ ft): Communication that is impersonal and voice must be projected, not being able to see subtle expressions

Trap Interviewing

• Providing false assurance or reassurance
• Giving unwanted advice
• Using authority
• Using avoidance language
• Distancing
• Using professional Jargon
• Using leading or biased questions
• Talking too much
• Interrupting
• Using “why” questions

Non-Verbal Behaviors of the Interviewer

• Positive behaviors: includes appropriate professional appearance and eye contact, moderate vocal tones, facilitate gesturing and open posture
• Negative behaviors: unacceptable appearance, standing above of the client, no eye contact, tense posture, fidgeting, frowning, yawns, looking at notes

Guidelines for Patient Interview

• Strident, high-pitched and too soft pitch tones are unacceptable
• Patients with hearing impairments must be approached to ensure proper communications

With Hearing Impaired Do

• Face them directly with access to sight and their aid is on/ or working
• Do speak slowly and clearly with simplified messaging
• Write if needed and be very patient

Visually Impaired

• Touch is important
• Call out the person's name before touching.
• Allow the person to touch you.
• Tell the person if you are leaving.
• Let the person know if others will remain in the room or if she or he will be alone.
• If you are in a group, always begin your comments by saying the name of the person
• to whom you are addressing.
• Treat the visually impaired person as you
• would a fully sighted individual.
• Find out from the individual the extend of
• her or his impairment. Legal blindness is not
• necessarily total blindness.
• Explain what you are doing, as you are
• doing it.
• Do not be overprotective.
• Be careful not to move things around in the
• room of a visually impaired person unless
• the person asks you to move something.

Communicating

• Anxious Client: provide limited information with structured formatting, also concise questions
• Cognitively Challenged: use yes/ no questions and speak slow
• Aggressive people: avoid loud tones instead speak softly with no erratic movements, empathy instead should be shown
• Manipulative Clients: apply limits and ensure no reasonable request are made or accepted.
• Seductive Clients: avoid all sexual contact and covert behaviors or report to superior
• Sensitive Issues: be aware of all your own emotions while asking simple open ended questions

Comprehensive Health History

• Biographic Data: Identifying data such as Name, age, gender, occupation, marital status, birthday,
• Source of the history
• Patient
• Family members
• Records
• Complete and clear description prompting visit, ask questions like Asa ang sakit ( S - site) , Kanus a nag sugod ang sakit ( O - onset), ( C - character), (R - radiation), (A - alleviating), (T - timing), (E- exacerbating factors), (Makapasamot sa sakit, S - severity
• Make sure a list of meds and allergies are taken to

Physical Assessment

• Inspection/ Color of Face: If cool/ warm (temp), inspect/observe skin by seeing the colors and palpate for different body signs
• The order is inspect, palpate(tough), percuss, and auscalate(sound/listen)
• While palpating test for: Turgor (Skin and Degree) and Edema
• Palpate/ Examine : Pulses, edema
• The levels of consciousnesses for patients are awake, alert, responsive to you and others
• Know how normal breaths and sounds are
• Palpate and test : Posture, gait, and motor activity/if they a body part is leaning and their speech

Techniques of Physical Assessment

• Inspection visual, Palpation (touch), Percussion(tap/listen), and auscultation (listen)

Percussion

• Percussion is done by striking or taping of the body surface in order to elicit characteristic sound
• Determine the location, size, and density of underlying structures/ detects presence of air
• the nurse inspects with the naked eye and with a lighted instrument/ lighting must see details

Skin Assessment

• Check the skin and make sure to use the right lighting
• While inspecting note hair skin, nails, lesions, lumps, pain, change in firmness color
• Ask questions about their living spaces and make sure to get as much info as possible
• If over 50 be aware of actinic keratosis

Skin Assesments and their Meanings

• Clubbing: nail over 180 change
• Bruised Nail: blood clot
• Longitudinal Melanonchia: Darkening for finger or toes
• Beau's line: transverse line due to temporary disturbance
• Koilonychia: spoon nails
• Onychophagy: bitting nails

Types Sound:

Loud musical drums

Stages Hair Fall

• If the hair strand has a bulb then has telegan if there isn't a bulb then is a Anagen
• Alopecia Aerate is suddenly localized
• Monilethrix: can't grow hair with brittle strands