ADPIE

• Lydia Hall - Coined the term nursing process
• Lydia Hall - Note Observation, Administration of care and validation
• Dorothy Johnson - Assessment, Decision Making, Nursing Action
• Ida Jean Orlando - Behavior, Nurses Reaction, Nurses Action
• Yura/Walsh - APIE
• Knowles - Discover, Delve, Decide, Do, Discriminate
• 1973 - Diagnosis is separated
• 1980 - diagnosis of actual and potential problems are delineated
• 1991 - ADPIE
• Dynamic and Cyclic - Continuous assessment and Evaluation
• Client-centered - Focuses on client
• Planned and Goal Directed - Scientific than traditional
• Universally applicable - Used in any age
• Problem oriented - Focuses on client problems
• Cognitive process - Use intellectual skill
• Heart of Nursing : Knowledge, Skill, Attitude
• Four types of Assessment: Initial, Ongoing, Focused, Emergency
• Initial comprehensive assessment - after admission and to established complete data
• Ongoing Assessment - composed of mini overview. After database is established. Perform everytime nurse patient interacts.
• Focused Assessment - does not take place after comprehensive exam. Specific concerns only.
• Emergency Assessment - whenever the client is in physiological or psychological crisis. Immediate. Identify nee overlook problems.
• Subjective Data - data elicited and verified by the client
• Objective data - data directly or indirectly observed through measurement
• Primary source of information : Client
• Method of data collection:

  Physical Examination

  Laboratory test

  Observation

  Interview

  Review of Records
• Observation - is a conscious deliberate skill that is developed through effort
• Interview technique - is an organized conversation with the client
• Phases of Interview:

  Orientation

  Working

  Termination
• Planning the interview and setting:

  Time

  Place

  Distance

  Sitting arrangement

  Language
• Working phase - gather information about the client's health status
• Orientation phase - the nurse introduction with the client
• Termination phase - the client should be given a clue that interview is coming to an end
• Open-ended questions - prompts the client to describe a situation in more than one or two words. Give the client a chance to speak freely.
• Types of interview technique:

  Neutral question

  Leading questions
• Neutral Questions - How do you feel about that?
• Leading questions - are you stressed about surgery tomorrow?
• Physical and examination techniques - IPPA
• FDAR:

  FOCUS (Problem)

  DATA (Planning)

  ACTION (Intervention)

  RESPONSE (Evaluation)
• Label - describes the patient's respond to an actual problem
• Action - process of analyzing data to arrive at nursing diagnosis