ADPIE, NCBSN, Sub vs Ob, SBAR

ADPIE - Assessment

Taking in subjective and objective data; gathering patient history, symptoms, vitals, test results.

Subjective Data

Patient's perspective: pain level, emotions, complaints, symptoms. Can come from family or caregivers.

Objective Data

Measurable/observable info: vital signs, lab results, physical findings, visible symptoms.

ADPIE - Diagnosis/Analysis

Analyzing what the data means. Formulating a nursing diagnosis that guides the care plan.

ADPIE - Planning

Creating goals (short- and long-term) and choosing evidence-based interventions in collaboration with the patient.

ADPIE - Implementation

Carrying out nursing interventions from the care plan; addressing potential barriers to care.

ADPIE - Evaluation

Evaluating the care plan's effectiveness and adjusting as needed based on patient progress.

RAPGTE - Recognize Cues

Assessment step, identify what data is most relevant to the patient's condition.

RAPGTE - Analyze Cues

Determine what the data means and how symptoms/signs connect.

RAPGTE - Prioritize Hypotheses

Decide which issue is most urgent or important to address first.

RAPGTE - Generate Solutions

Plan evidence-based nursing interventions based on the priority problems.

RAPGTE - Take Action

Implementation: Execute the chosen intervention to address the patient's needs.

RAPGTE - Evaluate Outcomes

Assess whether the intervention worked and modify care as needed.

Subjective Data Examples

"I feel dizzy", "I'm nauseous", "I'm in pain", family reporting behavior changes.

Objective Data Examples

BP 145/90, lab results, coughing, sweating, altered mental status, visible injuries.

SBAR - Situation

Why you're calling. State patient's name, age, and immediate concern/problem.

SBAR - Background

Relevant medical history, reason for admission, and baseline data.

SBAR - Assessment

Clinical findings, vital signs, changes in condition, your interpretation of the situation.

SBAR - Recommendation

What you think should happen next — suggest an action, order, or provider evaluation.