The Nursing Process and ADPIE Framework

Overview of the Nursing Process

  • The Nursing Process is a structured, client-centered framework for nursing care, summarized by the mnemonic "A DELICIOUS PIE" (ADPIE):

    • Assess
    • Diagnose
    • Plan
    • Implement
    • Evaluate

  • Clinical Documentation Warning:

    • The abbreviation CC (cubic centimeters) should be avoided because it can be mistaken for U (units) when handwritten or poorly written.
    • Always write mL or milliliters instead.

Assessment Stage

  • Core Definition:

    • The process of gathering essential clinical information and verifying that all collected data is clear and accurate.

  • Categories of Assessment Data:

    • Subjective Data (Stated Data):
    • Information directly stated or reported by the client.
    • Sources include client statements, health history (health hx), and client interviews.
    • Objective Data (Observed Data):
    • Measurable or observable information obtained directly through nurse assessment.
    • Sources include direct physical examinations, physical observations, vital signs (V. Signs), and laboratory data (Lab. Data).

Nursing Diagnosis Stage

  • Core Definition:

    • Interpreting gathered assessment data to identify and prioritize client clinical problems.
    • Must be a NANDA approved nursing diagnosis.

  • Characteristics of Nursing Diagnoses:

    • These are clinical judgments distinct from medical diagnoses (not medical).
    • Can be structured as a 2-part statement or a risk diagnosis.
    • Examples of problem identification and prioritization:
    • Risk of Falls related to confusion.
    • Fluid volume deficit related to surgery as evidenced by (aeb) tachycardia, low blood pressure (hypotension), and low hemoglobin.

Planning Stage

  • Core Definition:

    • Setting client goals to address and solve identified nursing diagnoses and prioritizing care outcomes.

  • Goal Setting Framework (SET SMART GOALS):

    • S – Specific
    • M – Measurable
    • A – Achievable / Attainable
    • R – Relevant / Realistic
    • T – Time Frame / Timed

  • Example SMART Goal:

    • Client will maintain a systolic blood pressure ≥100 mmHg\ge 100\,\text{mmHg} for my entire shift.

Implementation Stage

  • Core Definition:

    • Reaching established goals by executing specific nursing actions and implementing the plan created during the planning stage.

  • Practical Nursing Interventions and Actions:

    • Carrying out specified nursing interventions.
    • Turning and repositioning the client.
    • Reassessing oxygen saturation (O2O_2).
    • Administering intravenous or oral fluids.
    • Administering vasoconstrictors as ordered.
    • Delivering appropriate client care while verifying right consent.

Evaluation Stage

  • Core Definition:

    • Determining the outcome of established goals and assessing the client's progress and response to nursing care.

  • Key Evaluation Activities:

    • Determining the ultimate outcome of SMART goals (goals met, partially met, or unmet).
    • Evaluating client compliance with treatment plans.
    • Documenting client response to pain and pain management.
    • Modifying the care plan and assessing for any required changes.