Overview of
NURSING PROCESS
(ADPIE)
DEFINITION
It is the systematic, rational
method of planning and
providing nursing care
PURPOSE:
TO PROVIDE CARE FOR
CLIENTS THAT IS
INDIVIDUALIZED,
HOLISTIC, EFFECTIVE
AND EFFICIENT
CHARACTERISTICS OF THE NURSING
PROCESS
Cyclic and dynamic in nature
Client Centered
Adaptation of problem solving
Involves decision making
Interpersonal and collaborative
Universally applicable
Uses critical thinking
PHASES OF THE NURSING
PROCESS
A – Assessment
D – Diagnosis
P – Planning
I – Implementation
E – Evaluation
ASSESSMENT
ASSESSMENT
Systematic and continuous
collection, organization,
validation, interpretation and
documentation of data
Carried out during all the phases
of the nursing process
4 Types of Assessment
TYPE TIME PERFORMED PURPOSE
1. Initial During admission To establish a database
To monitor and/or identify a
2. Problem-
Ongoing process specific, new or overlooked
Focused problems
Emergency
To identify life-threatening
3. Emergency or crisis
problems
situations
Several months after To compare a client’s status
4. Time-Lapsed initial assessment over a period of time
Activities During Assessment
1) Data Collection
2) Validation of Data
3) Organization of Data
4) Documentation of data
Types of Data
Subjective (covert, symptoms)
– felt and experienced by the
patient
Objective (overt, signs)
– detected by an observer
Sources of Data
1) Primary – client
2) Secondary – family
members, friends, health
professionals, records
Methods Of Data
Collection
1. Observation
2. Interview
3. Physical Examination
DATA VERIFICATION
DATA ARE
VALIDATED WHETHER
COMPLETE AND
ACCURATE
DATA
ORGANIZATION
DATA ORGANIZATION
NURSE ORGANIZES AND
CLUSTERS THE
INFORMATION TOGETHER
IN ORDER TO IDENTIFY
AREAS OF STRENGTHS AND
WEAKNESSES
Assessment Models
1) Gordon’s 11 Functional
Health Patterns
2) Orem’s Self-Care Model
3) Roy’s Adaptation Model
4) Body System’s Model
GORDON’S FUNCTIONAL
HEALTH PATTERN
HEALTH PERCEPTION
NUTRITIONAL-METABOLIC PATTERN
ELIMINATION PATTERN
ACTIVITY-EXERCISE PATTERN
COGNITIVE PERCEPTUAL PATTERN
SLEEP-REST PATTERN
SELF PERCEPTION PATTERN
ROLE RELATIONSHIP PATTERN
SEXUALITY-REPRODUCTIVE
PATTERN
COPING-STRESS TOLERANCE
PATTERN
VALUE BELIEF PATTERN
DATA
DOCUMENTATION
BASIS FOR
DETERMINING QUALITY
OF CARE AND SHOULD
INCLUDE APPROPRIATE
DATA TO SUPPORT
IDENTIFIED PROBLEMS
Components of a Nursing Care Plan
Nursing Goals and
Assessment Interventions Evaluation
Diagnosis Objectives
Subjective Cues: Problem + Goal: First Format Met
Objective Cues: Etiology Desired Independent: Partially Met
Outcomes: Dependent: Not Met
Collaborative
Second Format
Observation
Prevention
Intervention
Treatments
Health
Promotion
Interventions
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