Nursing Process 101-08 (1)
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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.
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.
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