HANDOUT # 6

THE HEALTHCARE PROCESS

ADPIE- Assessment, Diagnosis, Planning, Implementation, Evaluation

Definition – A systematic, rational method of planning & providing healthcare.

Goals:
 Identify client‟s healthcare status & actual or potential health problems.
 Establish plans to meet identified needs.
 Deliver healthcare interventions to address identified needs.

Characteristics – The healthcare process is cyclical; components follow a logical sequence.

STEP OF THE HEALTHCARE PROCESS:

1. ASSESSING - Collecting, organizing, validating & documenting client data.
Purpose – To establish database about client‟s response to health concerns or illness & the ability to
manage healthcare needs.
Activity:
1. Establish database:
A. Obtain healthcare health history.
B. Conduct physical assessment.
C. Review client records.
D. Review healthcare literature
E. Consult support persons.
F. Consult health professionals.
TYPES OF DATA:
1. Subjective Data
– aka symptoms or covert data; described by client. Includes sensations, feelings, values, beliefs, attitudes,
perceptions; info from significant others.

2. Objective Data
– aka signs or overt data; detectable by an observer, measured, tested vs. standard; seen, heard,felt, smelled,
obtained by observation or PE; objective data validates subjective data.

SOURCES OF DATA:
1. Client.
2. Support People - for young, unconscious, confused clients.
3. Client Records - medical records, therapies, lab results.
4. Health Care Professionals – info with their previous contact w/ client.
5. Healthcare/ Medical Literature – reference books, journals for standards or norms.

DATA COLLECTION METHOD:

1. OBSERVING: Make use of sense
a. Notice the data
 b. Select, organize, interpret the data; focus on specific data.

2. INTERVIEWING: planned communication with a purpose.

Rapport: understanding b/n 2 or more people.

3. EXAMINING
PE: systematic data-collection method using observation (sense of sight, hearing, smell, touch) to detect health problems.

Uses techniques:
Chest
 inspection
 auscultation
 palpation
 percussion

Abdomen
 inspection
 auscultation
 percussion
 palpation

2. DIAGNOSING - analyzing & synthesizing data.

Purpose: To identify client strengths & health problems that can be prevented or resolved by collaborative & independent
healthcare interventions.

Activities:
1.1 Interpret & analyze data:
a. Compare data against standards.
b. Cluster or group data.
c. Identify gaps & inconsistencies.
1.2 Determine client strengths, risks, diagnoses, & problems.
1.3 Formulate Dx.
TYPES OF HEALTHCARE DIAGNOSES:

1. Actual Dx: client problems present during healthcare assessment. Based on presence of associated
signs and symptoms.
Ex. Ineffective Breathing Pattern Anxiety
2. Risk Dx: clinical judgment that a problem does not exist, but the presence of risk factors indicates that a
problem is likely to develop unless nurses intervene.
Ex. Risk for Infection (for clients w/ compromised immune system, like diabetes has higher risk than others)
3. Wellness Dx: describes human response to levels of wellness in wellness in individual, family or community
that have readiness for enhancement.
Ex. Readiness for Enhanced Family Coping
4. Possible Dx: evidence of health problem is incomplete or unclear. Needs more data to support it.
Ex. Possible Social Isolation r/t to unknown etiology (for an admitted elderly widow who lives alone, has no visitors and
happy to interact with healthcare staff)

Healthcare Dx for Health Perception/Health Mgt

1. Anxiety
2. Disturbed Body image
3. Fatigue
4. Fear
5. Ineffective Health Maintenance
6. Risk for Infection
7. Deficient knowledge
8. Powerlessness
9. Self-care Esteem
10. Disturbed sleep pattern
3. PLANNING: determine how to prevent, reduce, resolve identified client problems; support client strengths, how to
implement healthcare interventions in an organized, individualized, & goal-directed manner.

PURPOSE: To develop individualized care plan that specifies client goals/desired outcomes.

ACTIVITIES:

a. Set priorities & goals/outcomes w/ client.

b. select interventions.
c. Consult other health professionals
d. Communicate care plan to appropriate healthcare providers.
 4. IMPLEMENTING: carrying out the planned healthcare interventions.

PURPOSE: To assist client to meet desired outcomes; promote wellness; prevent illness; restore health; & facilitate coping
w/ altered functioning.

ACTIVITY:

a. Reassess client to update database.

b. Determine need for assistance.
c. Perform planned interventions.
d. Communicate what actions were implemented.

5. EVALUATING: measures the degree to w/c outcomes are achieved & identify factors that positively or negatively
influence goal achievement.

PURPOSE: To determine whether to continue, modify, or terminate the plan of care.

ACTIVITIES:

a. collaborate w/ client & collect data related to desired outcomes.

b. Judge whether outcomes have been achieved.
c. Relate actions to client outcomes.
d. Make decisions about problem status.
e. Review & modify care plan or terminate care.
f. Document achievement of outcomes & medication of care plan.

SAMPLE HEALTHCARE PROCESS

Assessment Cues Healthcare Dx Goals/Desired Interventions Rationale
Outcomes

S: “Mainit ang Elevated Body After 4 hours, Mr. 1. Advise bed 1. Decrease in activity will
pakiramdam ko” O: Temperature Patient shall rest. lessen Basal Metabolic Rate;
T-39C, P-86 2ndary to an on- demonstrate a temp thus, lowering release of body
R-24, BP-120/70 going infection of 37C. heat.
Flushed face,
Warm to touch
WBC-11,000

2. Loosen 2. Radiation will facilitate

patient‟s release of body heat the
clothing. environment.

3. Apply cold 3. Body heat will be

compress to conducted/transferred to the
forehead. compress.

4. Administer 4. TSB will open the skin

tepid sponge pores to facilitate the escape
bath. of heat through evaporation.

5. Administer 5. Paracetamol, an antipyretic,

paracetamol 500 will depress the hypothalamus,
mg as prn med. the heat-regulating center of the
CNS; thus, lowering production
of body heat.
 SAMPLE HEALTHCARE PROCESS

1. ASSESING:

Vital signs: T - 39˚ C; P-92 bpm, R – 28; BP – 120/80 mmHg. PE:

Skin dry, cheeks flushed, with chills.

Right lung: Inspiratory crackles w/ diminished breath sounds.

2. DIAGNOSING:

Ineffective Airway Clearance r/t accumulated mucus obstructing airways.

3. PLANNING: (Collaboration b/n Midwife & client )

Goal: Restore effective breathing pattern & ventilation .

Outcome Criteria: Have a symmetrical respiratory Plan of Care:

a. Coughing & deep breathing exercise q3h.

b. Fluid intake of 3000ml day.
c. Postural drainage daily.
4. IMPLEMENTING:

a. Deep breathing exercises q3h during the day.

b. Increase fluid intake.
c. Postural drainage every morning.

5. EVALUATING:

a. Failure of client to achieve

maximum ventilation. Re-evaluation: