THE NURSING PROCESS (ADPIE)

hi everybody I am net nursing guff and welcome to my channel in today's video we're gonna be talking about the nursing process so the nursing process is assessment diagnosis planning implementation and evaluation and what I'm going to do is I'm going to break down all of those categories for you and give a couple of examples so let's jump into it let's serve the assessment so assessment first thing we do and what assessment is is when we're gathering our data on our patient so this is subjective information and objective information and if you remember subjective information is anything the patient tells you all projective information is anything that we can observe or anything that we do like a lab test so some examples of data that we gather could be from x-rays lab results are head-to-toe assessment the interview and our observation of the patient so this is our assessment this is our data that we're gathering there's two types of assessments there is a comprehensive and a problem focused so comprehensive is exactly what it sounds like this is every single thing we're checking every single thing on this patient proudly focused is they came here for a specific reason they're being admitted for a specific reason a specific problem their chief complaints whatever you want to call it their reason for seeking care and that's what we're gonna focus on so an example of this could be pain so they came in because they're having pain we're gonna do our assessment and focus our assessment around that pain now I do want to say even if you're doing a problem focused assessment that doesn't mean you're gonna completely ignore everything else the rest of your assessment is still important too but we're first going to focus on the presenting problem so where do we get this data we have two sources the patient is number one and the patient should always be number one the patient is considered the best source because they know their bodies better than anybody else there are going to be times when you're taking care of a patient who is very confused right and they're probably not the most reliable reporters they're not going to be the best source in that situation but usually patient is number one number two is the chart their medical record and then others so their caregivers their family members or other people on the health care team the nurse who is leaving the shift before you who took care of that patient for 12 hours they know that patient better than you do if you've never met them before right so these are our two big sources of data and then some helpful tips when it comes to the assessment portion of the nursing process number one is learn as much as you can about that patient you are the patient expert you are the expert on your patient and an example of this is when somebody's coding and it's your patient everybody's going to be looking to you because you should know more than the charge nurse more than the CNA and even more than the doctor about this patient because you're the one that spends the most time with them so you are an expert on all of your patients so learn as much about them as you possibly can then number two after you've learned all this information you've gathered all this data figure out what's the most relevant some of its going to be important and some of its not going to be very important so that's part of critical thinking is you figuring out okay all this information I have what's the important stuff and then the final part of critical thinking is utilizing your own past experience now every patient is different everybody's an individual but if you've taken care of 50 people with pneumonia before you're going to kind of know the routine for your new patient with pneumonia use your past experience you're gonna know what hiccups could happen what consequences could happen or what things could get in the way so knowing your patient knowing what's best for them knowing the most important information about them and then using your own past experience to provide the best possible care this portion is the assessment part of the nursing process and it is probably the most important because if you mess up on this part you're gonna mess up on the rest of it it's gonna affect everything you do so the assessment first and most important part of the nursing process now that we've done our assessment we've gathered all of our data and we've ID'd our relevant information we're ready to move on to step two of the nursing process which is diagnosis in the diagnostic stage this is where we're identifying the problem now one thing I do want to point out is a nursing diagnosis is not a medical diagnosis they're very different it is not in our scope of practice to make medical diagnosis so example the doctor will diagnose the patient with pneumonia we will say ineffective airway clearance and I know you're probably thinking well how am I supposed to know that how am I supposed to know what diagnosis I'm allowed to use an app it's in your book you have a whole book on this this is the Nana book it has all of the approved nursing diagnoses that you can use this book is your friend learn how to read it and learn how to use it and it will be very helpful to you throughout your nursing career in nursing school so there are three types of nursing diagnoses there's the problem-focused which is exactly what it sounds like you're gonna focus on the main problem risk diagnosis which is focusing on potential problems future problems like maybe your patient is dizzy and confused so they are at risk for Falls there is a potential that they could fall that's a risk diagnosis and then the third one is the health promotion and then again exactly what it sounds like so promoting health healthy behaviors so when you look at your nanda book and you see all the different potential diagnoses you could use it can be very overwhelming there's a lot of choices so how do you know what to pick the first thing you're going to do is look back to your assessment look at your assessment ID the relevant info and then it's going to kind of narrow down your choices and it's going to get a lot easier for you to pick the appropriate diagnosis for your patient and then the second part is after you've picked it you're gonna write your diagnostic statement and there is a proper way to do this so the template is your diagnosis which is your problem related to your RT which is the etiology or the cause what caused your problem and then your as evidenced by AE B these are your signs and symptoms so an example whenever it inhere about pain so our nursing diagnosis is acute pain related to surgical incision so the surgical incision is what caused the pain so acute pain related to surgical incision as evidenced by so what's our proof that they're having pain the patient reported a 9 out of 10 pain and since that was subjective I put it in quotation that's a subjective part of our assessment it has to go in quotes because it's something they said so this is an example of our diagnostic statements we have our problem related to the cause of that problem and as evidenced by the proof our signs and symptoms all right so we've done our assessment we've figured out an appropriate diagnosis now it's time to make our plan so the next step is planning and in the planning stage this would we develop our goals and outcomes for our patient so what's the difference between a goal and an outcome a goal is a general statement it's a very broad statement about what we want to happen so it describes what we want to happen what experience do we want the patient to have an outcome is a lot more specific an outcome is a measurable change a little triangle if you weren't sure that means change that's just a little short-handed Nursing is a measurable change that must be achieved in order to meet the goal so things you can observe the patient do that's an outcome and I've written some examples of these so for a goal our example is the patient achieve pain relief by discharge so that's what we wanted to have them we want them to have pain relief our outcome is a little bit more specific the patient will report a pain of zero out of ten when you're writing an outcome statement make sure you're being smart about it so smart stands for specific measurable attainable realistic and relevant and timely so specific meaning just do one at a time you're gonna have a bunch to choose from and you're gonna think of a lot of them just pick one at a time M is for measurable if you can put a number on it that's the most ideal situation so for our example here I said the patient will report pain of zero out of ten so using the pain scale we can quantify this we can put a number on it that's measurable attainable is this something the patient can do or is willing to do for example you're not going to ask your bed-bound patient to go walking in the hallways it's not realistic right so making sure is attainable and then our for realistic is it something that they're capable of doing and on the side of note maybe they're capable of it maybe they're like physically they can do it but maybe they're not going to do it maybe you know like compliance wise it's not gonna happen so be realistic think of attainable outcomes for your patient something they're capable of doing is something that they will do and then the other arm is for relevant don't make outcomes that have nothing to do with what's going on with your patients and then finally T is timely put a timeframe on it people are more likely to achieve their goals and outcomes if you put a timeframe on it and that time could be by the end of the shift within the next eight hours or for our example here by discharge we want this to happen before discharge so put a timeframe on it and that's going to help them achieve those outcomes it's gonna make it easier for you to measure if they were able to achieve those outcomes now some of these are gonna be very short-term the saying you know by the end of the shift we want them to be able to do whatever some of them are going to be long-term especially if you are a community health nurse or you're working you know outside it's like a hospital setting maybe you're in case management or something and you're doing your care plans your timeframes could be longer they could be a month six months a year right if you're dealing with chronic disease and that's okay so don't be thinking that you have to have your time like this so yeah dammit figure it out before we go home today no no think about the time in relation to what we want them to do is it realistic for them to do what we want them to do in that time frame if not do we need to change that time frame and that's okay if we do so this is planning this is the third step in the nursing process all right now we're into the fourth step of the nursing process which is implementation this is us actually doing the things that we planned so implementation is the things you will do or we will help the patient to do to achieve our goals and outcomes that we set for them so some tips in the implementation stage making sure the things we want to do our relevance that they're actually going to help our patient and then make sure they're explainable so if somebody were to ask you why are you doing that why are you implementing that you can explain it you have a good rationale and when you write your statement you're gonna write for example our patient with pain surgical pain provide PCA as ordered so that is our implementation that's our intervention that we've chosen and then we explain why we've chosen that intervention with our rationale so our rationale for this is the IV route is preferred method of severe acute post-operative pain and that just didn't come from my brain that is something I read in mine and a book and so of course I'm gonna cite that so you want to cite it you don't want to take credit for your rationale gonna cite your rationale and your rationale explains why you chose the intervention you chose in your implementation stage now for the final step in the nursing process is the evaluation and what are we evaluating we're evaluating us ourselves what did we come up with our plan did it work was it good so in the evaluations we're addressing the goals and making judgments on them so where they met that's what we're asking ourselves that's the big question with evaluation where our goals met if yes then that's great we can discontinue the care plan because we don't need it anymore our goals are met if no the first thing you want to figure out is why why were our goals not met were they not smart outcomes were they not realistic were they not specific measurable timely or did something happen your patient was doing great they were getting up they were moving around and they slipped and fell in the hall and broke with her hip now they've had a change in condition if there's a change in condition that's obviously gonna change everything that's gonna change your whole care plan and that's okay that makes sense do not think that you did something wrong or that you failed or that you're a bad nurse or anything like that if your patients don't always yes if they don't always get a yes we met our goals it's okay if they don't meet their goals so figure out why and then once we figure out why change something so where was the error where did we go wrong was it in the beginning in the assessment do we not gather the relevant info did we gather information that wasn't important did we pick the inappropriate diagnosis was our diagnosis good but our plan related to our diagnosis wasn't good or what about our interventions they weren't good interventions they weren't smart interventions so figure out what went wrong or if it was because of a change in condition discontinue the whole care plan because maybe it's not relevant anymore it doesn't make sense for your patient in the way that they are right now and make a new one and that's okay we can do that I don't what you think like oh I have to always get it yes okay if your goal wasn't met that's okay you just need to explain why it wasn't meant so let's do an example of an evaluation continuing on with our patient who was having pain remember our goal that they would achieve pain relief prior to discharge we're going to say that they met that goal so here I have goal met the patient was able to achieve adequate pain control prior to discharge the patient reported a zero out of ten pain at discharge so that's the nursing process assessment diagnosis planning implementation and evaluation each step is really important and they all kind of build on each other so if you mess up one it kind of is like a domino effect and it messes up everything so be very diligent and very careful when you're making your care plans and going through the nursing process when taking care of your patients I hope this was helpful if you have any questions or comments just let me know if not I'll see you on the next one

Channel: That nursing prof

Views: 27,333

Keywords: ADPIE, Assessment, Nursing diagnosis, Care plan, Nursing, Nursing school, Planning, Diagnosis, Implementation, Evaulation, NCLEX, Patient, Fundamentals, nursing process, nursing (field of study)

Id: am9zN5calho

Length: 16min 23sec (983 seconds)

Published: Wed Mar 11 2020