ADPIE

• Nursing Process


  Critical thinking five step process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness
• Nursing Process Steps


  • Assessment
  • Planning
  • Implementation
  • Evaluation
• Assessment


  • Underlying disease process
  • Normal growth & development
  • Normal physiology & psychology
  • Normal assessment findings
  • Health promotion
  • Assessment skills
  • Communication skills
• Planning


  • ANA Scope & standards of nursing practice
  • Intellectual standards of measurement
• Implementation


  • Perseverance
  • Fairness
  • Integrity
  • Confidence
  • Creativity
• Evaluation


  • Previous patient care experience
  • Validation of assessment findings
  • Observation of assessment techniques
• Assessment


  Deliberate and systematic collection of information about a patient to determine the patient's current and past health and functional status and his or her present and past coping patterns
• Assessment


  1. Collection of information from a primary source(patient) and secondary source(family/friends, health professional and medical records)

  2. Interpretation and validation of data to ensure a complex database
• Critical thinking


  Ability to think in a systematic and logical manner with openness to question and reflect on reasoning process
• Critical thinking


  • Open-mindedness
  • Continual inquiry and perseverance
  • Willingness to look at each unique patient situation and determine which identified assumptions are true and relevant
• Patient-centered interview


  Nursing health history
• Gordon's Functional Health Patterns


  • Health perception-health management
  • Nutritional-metabolic
  • Elimination
  • Activity-rest
  • Sleep-rest
  • Cognitive-perceptual
  • Self perception-self concept
  • Role relationship
  • Sexuality-reproductive
  • Coping-stress tolerance
  • Value belief
• Comprehensive assessment


  Moves from general to specific
• Types of data


  • Subjective (patient's verbal descriptions of health problems)
  • Objective (observations/measurements of patient's status)
• Motivational interview


  Technique used often in counseling that allows you to become a helper in change process
• Motivational interview


  Addresses patient's ambivalence to medically indicated behavior change & supports patient's in making health care decisions in case in which there is more than one reasonable option
• Effective communication requires


  • Courtesy
  • Comfort
  • Connection
  • Confirmation
• Phases of an Interview

  1. Orientation & setting an Agenda

  2. Working Phase-collecting assessment/nursing health history

  3. Terminating an Interview
• Interview Techniques


  • Observation
  • Open-ended questions
  • Leading questions
  • Back channeling
  • Probing
  • Direct closed-ended questions
• Interpretation


  Determine presence of abnormal findings, recognize further observations needed to clarify information & begin to identify patient's health problems
• Validation


  Comparison of data with another source to determine accuracy
• Validation opens door for gathering more assessment data because it involves clarifying vague/unclear data