Nursing Process 101 - ADPIE Cheat Sheet

Systematic guide to patien­t-c­entered care
  > involves critical thinking skills and data collection

1. Assessment
2. Diagno­sis­/An­alysis
3. Planning
4. Implem­ent­ation
5. Evaluation
*although the steps are ordered, nursing is not linear and care is both cyclic and bidire­ctional

DOCUMENT! DOCUMENT! DOCUMENT! If it wasn't docume­nted, it wasn't done

first function of the nurse: data collection and docume­ntation
explore the pt's viewpoint
  > interview, physical examin­ation, observ­ation, functional assessment
  > initial, focused, organized, emergent
  > collect subjective & o­bje­­ctive data
  > pt demogr­aphics, past medical history, past surgical history
  > utilize database: patient medical records, labs and diagnostic results
  > gather info about pt's condition HPI, cc, vital signs and/or lab results
  > compre­hensive ROS review of systems
  > risk assess­ment: identify any potential health problems
  > inquire about related goals, experi­­ences, values & expect­­ation about healthcare system
  > cluster cues and data, make inferences & identify patterns & problems
  > must be: purpos­­eful, priori­­tized, complete, system­­atic, factual, relevant, documented
collect, analyze, validate, commun­­icate

Nursing diagnosis vs medical diagnosis
  > nursing diagnosis is human response to illness; unique to each patient
Use clinical judgement and analyze data; actual vs potential health problem, wellness
clarify exact nature of problem or risk to achieve overall outcome
> Identify how pt responds to health or life processes
> Identify factors contri­butes to problem; specific, critical and related
> Identify resources & strengths of pt
health problem prevented or resolved
> problem focused (actual)
> identify "at risk for" problems
> health promotion (wellness)
  - problem NANDA
  - etiology "­related to" or "­r/t­"
  - symptoms "as evidenced by" or "­AEB­"
*use nursing standards to help determine nursing diagnosis
One-part (diagn­osis), two-part (diagnosis + etiology) and three-part statements (diagnosis + etiology + s/s)

Plan of care
Design of plan of care results in preven­tion, reduction, resolution of pt health problems
  > Priori­ties: high, interm­ediate, low
  > MASLOW: physio­log­ical, safety, love/b­elo­nging, esteem, self actual­ization
  > SMART goals: Specific, Measur­able, Attain­able, Realistic, Timed
  > Short-term and long term
Steps
1. establish priorities and develop outcomes
  - indivi­dua­lized
  - culturally approp­riate
2. identify and document expected outcomes
3. identify and select nursing interv­ent­ions: integrate EBP and nursing standards
4. commun­icate and document care plan

Identify expected outcomes and goals and criteria for success related to the pt's needs

Implement the plan of care, nursing interv­ention actions
Specify the nursing actions and interv­ent­ions, who, what, when, how
> plans are carried out, safely and timely
> plans are evidence based
> coordinate care delivery
> provide health teaching and health promotion
> document implem­ent­ation and any modifi­cations

indepe­ndent, dependent, and collab­ora­tiv­e/i­nte­rde­pendent
  - indepe­ndent: nurse initiated, w/o MD orders
  - dependent: MD orders (all medica­tions)
  - interd­epe­ndent: PT, OT, social worker, RT, dietician

direct and indirect
  - direct: intera­ction with the patient (ie. v/s, medication admini­str­ation)
  - indirect: no intera­ction with the patient (ie. speaking with MD, creating plan of care)

Re-ass­essment of how well pt has achieved expected therap­eutic outcomes
  ongoing through nursing process

> resolve health problems
> prevent potent­ially new problems
> collect data
> maintain a healthy state/ health promotion
> document findings using clinical judgement
> terminate, continue, modify
> goals met, partially met, unmet

Include the pt and their family by interp­reting and summar­izing findings
if the goal(s) has not been met, reasse­ssment and revision of plan of care*