Nursing Process(ADPIE)

Nursing Process(ADPIE)

1. Implementation

   • key elements to achieve success
     • Resources
     • Interpersonal/cognitive skills
     • Prioritize the intervention
     • collaboration
     • ongoing assessment

2. Assessment

   • Types of Assessment
     • Initial Assessment
       • after admission
     • Problem Focused Assessment
       • determine specific problem
     • Emergency Assessment
       • identify life-threatening problem
     • Time lapsed-Reassessment
       • several months after initial assessment to compare with the baseline data
   • Types of Data
     • Primary VS Secondary
     • Subjective VS Objective
   • Data collection method
     • Review of medical record
     • Observation
     • Interview
     • Physical Examination

3. Diagnosis

   • Types of diagnosis
     • Nursing Diagnosis
       • Format of nursing diagnosis (PES format)
         • 1. Problem
           • nursing diagnosis
         • 2. Etiology
           • related factors
         • 3. Defining characteristic
           • clinical signs and symptoms
       • types of nursing diagnosis
         • Actual Nursing diagnosis
           • Acute pain related to post-operative wound as evidenced by client complain of pain with pain score 8/10.
           • present health problem + sign & symptoms
         • Risk nursing diagmosis
           • Risk of impaired skin integrity related to physical immobility associated with lower limbs injury.
           • Possible developing health problem+ risk factors
     • Medical diagnosis

4. Planning(SMART)

   • 1. Goals+ use measurable words
     • types of goals
       • short term goal
         • hours to days
       • long term goal;
         • weeks to months
     • SMART
   • 2. expected outcomes
     • Example:  Goals + expected outcomes Goal:  Mr Chan will express that diarrhea resolved in 2 days. Expected outcomes:  1. Mr Chan will verbalize the abdominal cramping has been relieved in 4 hours. 2. Mr Chan will have decreased frequency of defecation by tomorrow. 3. Mr Chan will restore the normal bowel elimination with formed soft stool in 2 days.  
     • SMART
   • 3. nursing interventions (with specific rationales)
     • Nursing intervention for acute pain of left leg injury. 1. Assess Mr Chan's pain severity with pain score and nature . Rationale:  Severity of pain helps to decide pain management for further actions and it can be used for evaluation the effectiveness of the intervention. 2. Administer analgesics(e.g. Paracetamol) to Mr Chan as physician's prescription. Evaluate and record the effectiveness and adverse effect of analgesics. Rationale: Paracetamol helps clients to reduce the intensity of pain signals to the brain by reducing the production of prostaglandins ,which cause pain. 3. Educate Mr Chan indication and side effect of analgesics. Rationale: Provide client with medication knowledge can help to promote proper use and prevent overuse of the drug. 4. Assist Mr Chan to elevate lower limb with pillow. Rationale: Elevation of injured leg can promote fluid return so as to prevent leg edema which may cause pain more severe. 5. Provide Mr Chan a cold pad over injured limb 15-20 minutes every hours as directed. Rationale: Cooling effect reduces edema and pain sensation. 6. Monitor Mr Chan's vital signs every 4 hours. Rationale: Pain may cause haemodynamics (increase BP, RR changes) 7. Teach Mr Chan's relaxation skills to reduce pain, e.g. deep breathing exercise. Rationale: Relaxation promotes the human brain to secrete endorphins, which have opiate-like properties that relieve pain. 8. Encourage Mr Chan to perform activities, such as listening to music, watching TV, reading,,, to distract from pain. Rationale: It is a useful way to reduce pain by distraction. 9. Re-assess Mr Chan's pain score. Rationale: Evaluate the effectiveness of the interventions and modify the plan if needed.
     • classification of nursing intervention
       • independent nursing intervention
         • nurse-prescribed
       • interdependent nursing intervention
         • collaborative
       • dependent nursing intervention
         • doctor-prescribed
   • SMART
     • Specifc
     • measurable
     • attainable
     • relististic
     • time-bound

5. EVluation

   • Goal is met
     • care plan is complete
   • Goal is partially mwt
     • care plan is continued or modified.
   • Goal is not met
     • care plan is modified + re-do the plan

6. Documentation

   • Functions
     • communicate care
     • Identify pattern
     • Evidence-based care
     • Basis for evalution
   • Principle
     • follow instruction guideline
     • document in correct client record
     • include date and time
     • write in permanent ink
     • write in legibly and neatly
     • do not leave space
     • do not erase
     • correct spelling & grammar
     • sign each entery
     • use authorized abbreviations