N101-NURSING

PROCESS
ADPIE
By: Donna Hess RN, MS
Assessment:
 Purpose: To establish a database about the client’s
health, illness and ability to manage healthcare
needs.
 Nursing Activities: Collect & Sort Data
1.Collect and Update
 -obtain history
 -conduct physical assessment
 -review client records
 -review nursing literature
 -consult support persons
 -consult health professionals
2.Organize Data
3.Validate Data
4.Communicate – Document Data
Nursing Diagnosis:
 Purpose: To identify client strengths and
problems (health) that can be prevented or
resolved by collaborative and independent
nursing interventions. To analyze and
synthesize data to develop a list of nursing
diagnosis and collaborative problems.
 Nursing Activities: Interpret & Analyze Data
1. Compare data with standards
2. Cluster or group data
3. Identify gaps and inconsistencies in data
4. Determine client’s strengths, risk & problems
5. Formulate nursing diagnosis & document on Plan of Care
6.
7.
Planning
 Purpose: To develop an individualized plan of care
that has specific goals/desired outcomes and related
nursing interventions to reach the goals/outcomes.
 Nursing Activities: Goals, Outcomes &
Strategies
1. Set priorities & goals/outcomes with client involvement
2. Write goals/outcomes
3. Select nursing strategies/interventions (determine how to
prevent, reduce, & resolve client problems)
4. Consult with other health care professionals
5. Write nursing orders & nursing care plan (including review of
MD orders)
6. Communicate nursing care plan to healthcare providers
involved in the client’s care
Implementation:
 Purpose: To assist the client to meet desired
goals/outcomes, promote wellness, prevent
illness & disease, restore health, and assisting in
client coping.
 Nursing Activities: Initiate Plan of Care
1.Determine the client’s need for assistance
2.Perform or delegate planned nursing interventions
3.Communicate nursing actions & plan of care
4.Document care & client responses to care
5.Reassess the client to update the database & plan of care
6.
7.
Evaluation:
 Purpose: To determine whether to continue,
modify (change) or terminate the plan of care.
Measure goals/outcomes to see if they have
been achieved and identify factors that
positively or negatively influence the goals.
 Nursing Activities: Reassess
1.Determine if goals/outcomes have been achieved
2.Collaborate with client & collect data related to set goals
3.Relate nursing actions to client outcomes
4.Make decisions about status of problems (nursing diagnosis)
5.Review and modify the plan of care & document
achievement of modified plan of care
6.
7.