The Five Step Nursing Process Explained | Intro to ADPIE | Lecturio Nursing

Summary

The video script introduces the ADPIE nursing process, a five-step approach essential for patient care in clinical settings. It emphasizes the first step, Assessment, where nurses gather and analyze information about the patient's condition from various sources, including the patient, family members, healthcare providers, and medical records. The script highlights the importance of critical thinking in verifying and interpreting this information to identify the patient's priority health problems, setting the foundation for the subsequent steps of diagnosis, planning, implementation, and evaluation.

Takeaways

• 📝 The ADPIE process is a fundamental five-step approach in nursing that includes Assessment, Diagnosis, Planning, Implementation, and Evaluation.
• 🔍 Assessment is the first step of the ADPIE process, where nurses gather information about the patient's condition through various means such as a head-to-toe assessment, medical records, and family input.
• 🏥 Nursing assessment is crucial for patient care and involves identifying the priority health problems that affect the patient's overall health and well-being.
• 💬 Communication is key in the assessment phase, as nurses collect information directly from the patient, which is considered the best source, and also from secondary sources like family members and healthcare providers.
• 🔑 After assessment, nurses use this information to make a nursing diagnosis, which is a common language among nurses to identify the patient's priority problem, distinct from a medical diagnosis.
• 📋 The planning phase involves creating a plan of care with specific goals and interventions aimed at improving patient outcomes, setting expected outcomes for the patient's condition.
• 🛠️ Implementation is the action phase where nurses carry out the planned interventions to address the identified nursing diagnoses and improve the patient's condition.
• 🔄 The evaluation phase is about determining if the set goals were met and if the outcomes were achieved; if not, the ADPIE process may need to be revisited and adjusted.
• 🤔 Critical thinking is essential in the assessment phase, requiring nurses to not only collect but also verify and analyze the information to understand its relevance to the patient's condition.
• 👨‍⚕️ The nursing process is an organic part of a nurse's work on the unit, used to systematically provide care to patients in a clinical setting.
• 📈 The ADPIE process helps nurses to be systematic and thorough in their approach to patient care, ensuring that each step is carefully considered and executed to achieve the best patient outcomes.

Q & A

What is the ADPIE process in nursing?

The ADPIE process is a five-step approach in nursing that stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation. It is used to provide care to a client systematically.

Why is the Assessment step so important in the ADPIE process?

Assessment is crucial as it is the first step where information about the client's condition is gathered. It forms the basis for identifying health problems and creating a plan of care.

What is the difference between a medical diagnosis and a nursing diagnosis?

A medical diagnosis is a professional judgment about the presence and nature of a disease, while a nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.

How do nurses gather information during the Assessment phase?

Nurses gather information through a head-to-toe assessment, reviewing medical records, and talking to the patient, family members, and healthcare providers.

What is the purpose of the Planning phase in the ADPIE process?

The Planning phase involves creating a plan of care with specific goals, actions, or interventions aimed at improving the patient's condition and setting expected outcomes.

What does the Implementation phase (I of ADPIE) involve?

Implementation is the phase where nurses perform the planned interventions to help improve the patient's condition, as identified and planned in the previous steps.

What is the Evaluation phase in the ADPIE process and why is it important?

Evaluation is the final phase where nurses assess whether the goals set in the Planning phase were met and if the outcomes were achieved. It's important for determining if the care plan needs to be adjusted.

How does the ADPIE process help in a clinical setting?

The ADPIE process helps in a clinical setting by providing a structured approach to patient care, ensuring that all aspects of care are considered and that the patient's needs are met effectively.

What is the significance of using a 'pie image' to discuss the ADPIE concepts?

The pie image is used to visually represent the different steps of the ADPIE process, with each step being a 'slice' of the pie, emphasizing the interconnectedness and equal importance of each phase.

Can you provide an example of a nursing diagnosis based on the script?

An example given in the script is impaired breathing, which could be a nursing diagnosis for a patient medically diagnosed with pneumonia.

How does critical thinking play a role in the Assessment phase?

Critical thinking is essential in the Assessment phase for verifying the accuracy of the collected information, analyzing it, and interpreting how it applies to the patient's condition.

Outlines

00:00

📝 Introduction to the Nursing Process ADPIE

The video script introduces the ADPIE nursing process, emphasizing its importance in nursing school and clinical settings. ADPIE stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation, representing a five-step approach to patient care. The script uses a pie analogy to explain these steps, starting with Assessment, which involves gathering information about the patient's condition through various means such as a head-to-toe assessment, medical records, and family input. The focus is on identifying the priority problem and using nursing diagnoses for clear communication among nurses.

Keywords

💡ADPIE

ADPIE stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation, which is a systematic nursing process used to provide comprehensive patient care. It is central to the video's theme as it outlines the five-step approach that nurses follow to address patient needs. The script repeatedly emphasizes the importance of ADPIE in nursing practice.

💡Nursing Assessment

Nursing Assessment is the first step in the ADPIE process and involves gathering information about a patient's condition. It is crucial for understanding the patient's health status and identifying priority problems. The video script discusses this step in detail, highlighting its significance in the nursing process and patient care.

💡Patient Care

Patient Care refers to the healthcare services provided to patients to ensure their well-being. In the context of the video, patient care is the overarching goal of the ADPIE process, with each step designed to contribute to the overall health and improvement of the patient.

💡Nursing Diagnosis

A Nursing Diagnosis is a clinical judgment about an individual's response to a health problem or life process. It differs from a medical diagnosis as it is specific to nursing practice. The script uses the example of pneumonia, where the medical diagnosis is pneumonia, but the nursing diagnosis might focus on impaired breathing.

💡Plan of Care

A Plan of Care is a documented strategy outlining the goals, interventions, and expected outcomes for a patient. It is created after identifying the nursing diagnosis and is a key component of the ADPIE process. The script mentions this as the phase where nurses set goals and specific actions for improving patient outcomes.

💡Implementation

Implementation, represented by the 'I' in ADPIE, is the phase where nurses carry out the interventions detailed in the Plan of Care. It is the action phase where the nurse actively engages in patient care to address the identified health issues, as discussed in the video script.

💡Evaluation

Evaluation is the final step in the ADPIE process, where nurses assess whether the goals set in the Plan of Care have been met and determine if any adjustments are needed. The script describes this as a critical phase to determine the effectiveness of the care provided and to make necessary changes.

💡Critical Thinking

Critical Thinking is the process of analyzing and evaluating information to form a judgment. In the context of the video, it is essential for nurses during the Assessment phase to interpret and apply gathered information accurately to the patient's condition, ensuring that the care provided is based on a thorough understanding of the patient's needs.

💡Primary Sources

Primary Sources are the original sources of information, which in the case of nursing, is the patient themselves. The script emphasizes that the best source of information for a nurse is directly from the patient, as they can provide firsthand accounts of their symptoms and experiences.

💡Secondary Sources

Secondary Sources are supporting sources of information that complement the primary sources. In the script, these include family members, healthcare providers, and medical records, which can provide additional insights into the patient's condition when direct information from the patient is not sufficient.

💡Interventions

Interventions are actions or measures taken to improve a patient's health condition. The script refers to interventions as part of the Plan of Care, where specific actions are identified to address the nursing diagnosis and contribute to the patient's improved health outcomes.

Highlights

Introduction to the ADPIE nursing process, a fundamental approach taught in nursing schools and used by nurses in clinical settings.

Explanation of the five-step ADPIE process: Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Emphasis on the importance of nursing assessment in gathering information about the patient's condition through various sources like head-to-toe assessments, medical records, and family members.

Discussion on using nursing diagnosis as a common language among nurses to identify and communicate the priority problem for the patient, distinct from a medical diagnosis.

Example given of a patient with pneumonia, where the nursing diagnosis focuses on impaired breathing rather than the medical diagnosis.

Description of the planning phase where nurses create a plan of care with goals, interventions, and desired patient outcomes.

Overview of the implementation phase, where nurses perform the planned interventions to improve the patient's condition.

Importance of the evaluation phase in determining if the set goals were met and if the outcomes were achieved, with a possibility of revisiting the ADPIE process if needed.

Focus on the assessment phase, which is central to identifying major health problems contributing to the patient's overall health and well-being.

Emphasis on the critical thinking approach in the assessment process, involving collection, verification, and analysis of information.

Identification of the client as the best source of information, with secondary sources including family members, healthcare providers, and medical records.

Highlighting the need for nurses to use critical thinking skills to interpret gathered information and apply it to the patient's condition.

The ADPIE process is presented as an organic and essential part of nursing practice, not just a theoretical framework.

The transcript provides a practical application of the ADPIE process, showing how it can be used in real-world nursing scenarios.

The importance of using a common language in nursing to ensure clear communication and understanding of patient issues among nursing staff.

The transcript serves as an educational tool for nursing students and professionals, enhancing their understanding of the nursing process.

The ADPIE process is depicted as a cyclical and iterative approach, allowing for continuous improvement in patient care.

The transcript underscores the role of assessment in the overall nursing process, setting the foundation for effective patient care.

Transcripts

Hey guys, welcome to the series of ADPIE

also known as the nursing process.

You're going to hear this a lot through your nursing school,

and we do this a lot organically as a nurse on the unit.

But we're going to talk about this process,

and how it can help you in your clinical setting?

So the first step of ADPIE is nursing assessment.

And as you guys have been taught

nursing assessment is so important in regards to patient care.

So, we're going to talk about this process,

and why it's relevant to you?

So let's talk about the nursing process first.

This is a five-step approach of how you provide care to a client.

So when we talk about five-steps,

it is the A, the D, the P, the I, and the E.

The ADPIE.

So we're briefly going to talk about these steps first.

Just to introduce the nursing process to you.

And of course, we're going to use a pie image.

It's only fitting.

So we're going to use this to discuss our ADPIE concepts.

So let's take a look at the first piece of the pie

called assessment.

As you all know,

this is where we gather information about the client's condition.

Now, we're going to do this

by like a head to toe assessment, for example,

gathering information from our patient,

the medical records that are available,

and even the family members that are around our patients.

And the assessment piece is the part we're going to focus on today.

So once we start with our assessment,

just explain a process first.

We use our assessment to decide what the problem is as a nurse.

Here, we're basically trying to figure out

what the priority problem is.

So we use a common language called a nursing diagnosis.

It's not a medical diagnosis to use common language.

So, nurse to nurse,

we know what the priority problem is

for the patient.

So, here's an example of this.

Maybe your patient has an impaired breathing issue.

So the patient may have a medical diagnosis of pneumonia,

but as a nurse, this is not within our scope

to diagnose.

So therefore, we use a nursing common language

called nursing diagnosis to discuss the patient issue.

Next, we're going to make a plan for our patients

once we've identified that priority problem.

So the plan is going to look like a plan of care,

goals for our patients, specific actions or interventions,

to help improve that patient outcome.

And also, set some outcomes of where we want our patient to get to

and how much better we want them to be.

So next is what I call the action phase.

This is the I of the pie, the implementation phase.

This is where we actually perform those interventions

to help improve our patient's condition.

And lastly, and most importantly, is the evaluation phase.

This is if where we determine in that planning phase.

Did we meet these goals, or not?

Do we need to change things up?

Did those outcomes, were those met?

If not, we restart over on that ADPIE process.

So again, today, we're going to focus on the piece of assessment,

the A of the pie.

So in the assessment process,

this is where the nurses are going to gather information,

we're going to identify those major health problems

that contribute to the patient's overall health and well being.

So let's talk about assessment.

Guys, this is a big piece of what we do

and a big foundational piece of what we do as a nurse.

So when you think about assessment,

I want you to think

that there's a critical thinking approach to this.

So of course, it's collecting information,

but we also have to verify that information, right?

It's got to be the right information.

Then we've got to analyze the information that we have.

So we're talking about collecting information.

Who do we collect it from?

Well, the best source guys is the client.

Always, we're going to tell you the best source of information,

of course it's the client themselves.

This could mean from the assessment information we get from the client,

or what the client tells us is the issue.

And our secondary sources,

which is our backup or supporting sources

is of course going to be

the family member that maybe knows the patient really well

or lives with the patient.

The health care providers, and the medical record information.

Now, once we gather

all those primary, secondary sources of information,

we've got to actually use our critical thinking skills,

and interpret that info,

and see how it applies to our patient condition.