LPN ~ Nursing Fundamentals Ch 2, The Nursing Process, ADPIE Defined

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The Process of Nursing (Nursing Process)
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Series of 5 goals that lead to accomplishing some goal or purpose.
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Steps 1 of Nursing Process
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Assessment
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Assessment
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” Initial Interview” The Collection, Organization, Interpretation, Verification, and Documentation of DATA.
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Assessment Purpose
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Create an organized database regarding client’s health. (Holistically)-Identify health-promoting behaviors, and actual/potential health problems.
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Assessment Organized by
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Body System Method
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3 Types of Assessments
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Comprehensive=Complete, Focused=Limited, Systemic=Monitoring
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Assessment Data Sources
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Primary=Client and Secondary=NOT Client
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Types of Data
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Objective=Measureable/Observable and Subjective=Perceptions/Opinions
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Interpreting Data
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Distinguish between relevant or irrelevant. Identify patterns of cause and effect.
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Validating Data
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Prevents Misunderstandings, Omissions, Inferences, and Conclusions.
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Documenting Data
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Record or Call? You have to decide. Documenting essential for accurate communication between health care team members.
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Documenting
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CYA= Cover Yo Ass, Ya didn’t document it, Ya didn’t do it!
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Step 2 of Nursing Process
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Diagnosis
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2 Types of Diagnosis
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Nursing Diagnosis and Medical Diagnosis
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Nursing Diagnosis
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Clinical judgement about response to actual or potential health problems.
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Medical Diagnosis
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Clinical judgement by physician, determines specific condition.
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Step 3 of Nursing Process
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Planning- Develop individualized plan of care for client.
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Step 4 of Nursing Process
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Implementation- Performance of interventions identified during planning.
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Nursing Intervention
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Independent-Does NOT require and order. Dependant- Requires physician order.
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Step 5 of Nursing Process
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Evaluation- Determines if client’s goals have been met, partially met, or not met.
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Nursing Process Defined
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Systemic method providing individualized, holistic, effective, and efficient client care, regardless of age and setting.
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Nursing Care Plan
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Written guide of strategies to be implemented to help client achieve optimal health. begins on admission and continues until discharge.

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