Nursing Process: ADPIE Overview and Data Types

Nursing Process

• Systematic and rational method used for planning and providing individualized nursing care.
• Identifies a client's health status, actual or potential healthcare problems, and needs.
• Establishes plans to meet identified needs.
• Delivers specific interventions.

Overview of the Nursing Process

• Consists of assessing, diagnosing, planning, implementing, and evaluating.
• Identifying outcomes may be included between diagnosing and planning.
• Each phase influences the others, creating overlapping and continuous processes.
• Assessment continues during the implementation and evaluation phases.
• ADPIE is an acronym for the nursing process: Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Assessment

• Involves collecting, verifying/validating, and organizing data.

Types of Data

• Subjective data includes symptoms or covert data, apparent only to the person affected, such as feelings, beliefs, and perceptions.
• Objective data involves signs or overt data detectable by an observer, measured against accepted standards, and obtained through observation or physical examination.

Sources of Data

• The client is the best source unless they're too ill, young, or confused.
• Family members can be secondary sources when the client can't communicate.
• Support people like family/caregivers can provide secondary subjective/objective data.
• Client records (medical, therapies, lab records) help avoid repeated questioning.

Data Collection Methods

• Observing involves gathering data using senses like sight, smell, hearing, and touch.
• Examining is a systematic method using observation, inspection, auscultation, palpation, percussion, vital signs, height, and weight measurements.
• A cephalocaudal (head-to-toe) approach may be used during examination.
• A screening examination involves a review of systems.

Validating Data

• Validation involves double-checking data to ensure accuracy and completeness.
• Validation ensures agreement between objective and subjective data.
• The process obtains overlooked information.
• Cues are subjective or objective data directly observed by the nurse.
• Inferences are the nurse's interpretations based on cues.

Documenting Data

• Client data should be recorded factually without interpretations.
• Record subjective data with quotes in the client's own words.

Nursing Diagnosis

• NANDA International defines, refines, and promotes a taxonomy of nursing diagnostic terminology.
• Taxonomy is a classification system arranged based on principles.
• Activities preceding diagnosis are directed toward forming nursing diagnoses, and all subsequent steps flow from these.
• Critical thinking skills are used to interpret data and identify client strengths/problems.

Definitions Related to Nursing Diagnosis

• Diagnosing is the reasoning process.
• Diagnosis is a statement about the nature of a phenomenon.
• Diagnostic labels are standardized NANDA names for diagnoses.
• Etiology is the causal relationship between a problem and its related factors.
• Nursing diagnosis is a problem statement consisting of a diagnostic label plus etiology.
• Professional nurses are responsible for making nursing diagnoses, including only health states they are educated and licensed to treat.
• Diagnosis involves thorough data collection.
• Nursing diagnoses exist on a continuum of health states.

Status of Nursing Diagnoses

• An actual diagnosis means the problem is present at the time of assessment, with associated signs and symptoms.

Formulating Diagnostic Statements

• Basic three-part statements follow the PES format: Problem, Etiology, and Signs/Symptoms.
• PES format is recommended for beginning diagnosticians.
• List signs and symptoms grouped by subjective and objective data.

Planning

• Deliberate, systematic, problem-solving phase of the nursing process.
• Nursing interventions are treatments performed to enhance patient outcomes.
• Nurses are responsible, but client input is essential.

Types of Planning

• Planning begins with the first client contact and continues until the nurse-client relationship ends.
• Planning is multidisciplinary.

Implementing

• Involves performing specific nursing actions needed to carry out interventions.
• It is the fifth standard of the ANA Standards of Practice.
• Actions include coordination of care, health teaching/promotion, and consultation.

Relationship of Implementing to Other Nursing Process Phases

• The first three phases (assessing, diagnosing, planning) provide the basis for nursing actions.
• Specific nursing activities and client responses are documented.
• Results are examined during the evaluation phase.

Process of Implementing

• Reassessing the client is crucial.
• Determining the nurse's need for assistance.
• Implementing nursing interventions.
• Supervising delegated care.
• Documenting nursing activities.
• Reassessment ensures the intervention is still needed.
• The client's condition may have changed.
• Direct care involves treatments performed through interactions with patients (ADL, physical care, counseling, teaching, preventive measures).
• Indirect care involves treatments performed away from the patient but on the patient's behalf (managing the environment, documentation, interdisciplinary collaboration).

Evaluation

• Evaluation assesses the patient’s response to nursing interventions.
• Comparing the patient’s response to outcome criteria or goals.

Purpose Of Evaluation

• To assess the patient’s response to interventions to attain goals and reach optimal health.
• Four indicators reflect a nurse’s ability to perform evaluation:
  • Examine the results according to clinical data collected.
  • Compare achieved effect with goals and expected outcomes.
  • Recognize errors.
  • Understand a patient situation, participate in self-reflection, and correct errors.