Nursing Process: Step 1 - Assessment Phase

The Nursing Process and the ADPIE Framework

• The nursing process is a five-step systematic approach to patient care designed to deliver structured, individualized clinical care.

• The acronym ADPIE defines the five sequential steps of the nursing process:

  • $A$ - Assessment
  • $D$ - Diagnosis
  • $P$ - Planning
  • $I$ - Implementation
  • $E$ - Evaluation

• Sequential Order: Assessment ($A$) comes before Implementation ($I$) and treatment interventions in standard clinical workflows.

Step 1: Assessment Definition and Purpose

• Assessment serves as the first and baseline step of the nursing process.

• The fundamental purpose of assessment is to collect baseline data about the patient in order to properly understand their status and determine how to treat them.

• Initial assessments are illustrated through an evaluation of Patient Doug, assisted by the assessed man with a mechanical clock.

Components of Clinical Assessment Data

• Health History:

  • Symbolized by the health history book.
  • Data Source: Information gathered directly from the patient and/or the patient's family.
  • Core areas gathered during health history collection include:
  • Allergies
  • Current medications
  • Past medications
  • Surgeries
  • Family health histories
  • Physical activities
  • Psychosocial behaviors
  • Nutrition habits

• Objective Data:

  • Symbolized by objective observation with a data sheet.
  • Definition: Measurable and observable clinical data.
  • Clinical Terminology: Recognized as signs.
  • Specific objective parameters include:
  • Vital signs:
    • Body temperature
    • Respiratory rate
    • Heart rate
    • Blood pressure
  • Diagnostic tests

• Subjective Data:

  • Symbolized by the subjective thought bubble.
  • Definition: Information collected from the patient's personal perspective or point of view.
  • Clinical Terminology: Recognized as symptoms.
  • Specific subjective parameters include:
  • Patient feelings
  • Personal concerns
  • Rating on a pain scale
  • Direct patient presentation example: Patient Doug expressing, "I feel awful. I really do."

Nursing Exam Keywords for Assessment Questions

• Stem Analysis Strategy: Questions on nursing exams contain specific keywords or phrases in the stem to alert the test-taker that the item is asking about the assessment portion of the nursing process.

• Key Assessment Terms and Mnemonic Associations:

  • Identify:
  • Symbolized by a magnifying glass used to inspect and assess Patient Doug.
  • Focuses on recognizing baseline clinical details and patient findings.
  • Determine:
  • Symbolized by the determiner (also referred to as the D terminator using scanning skills to compile files).
  • Focuses on evaluating parameters to establish clinical findings.
  • Obtain Information:
  • Symbolized by assessment obtaining files.
  • Focuses on gathering baseline records, clinical history, and initial patient data.

Assessment Prioritization Rules and Exceptions

• Standard Treatment Rule:

  • Assessments must be fully conducted before treatments or interventions take place (represented symbolically as completing assessments before receiving treats).
  • A nurse should not implement interventions until a complete assessment has been performed to ensure accurate and safe treatment.

• Immediate Hazard Exception:

  • The sole exception to performing a complete assessment prior to treatment occurs in emergency scenarios where the patient is at risk of immediate injury or death.
  • In life-threatening emergencies, immediate life-saving stabilization takes priority over completing a full systematic assessment.