How did you remember the nursing process?

the nursing process is a series of 5 steps we use to solve a problem. the process can be used in the real world to solve problems as well. this is my analogy of the nursing process applied to a real world problem. it is posted on a number of threads around the allnurses site:

adpie is the abbreviation that is used to name the 5 steps.

• a - assessment
  
• d - diagnosis
  
• p - plan
  
• i - implementation
  
• e - evaluation
  

here is the outline i have in current development with regard to adpie and care planning. early forms of it were posted on this thread in the nursing student discussion forum: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans.

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
   • a physical assessment of the patient
     
   • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
     
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians (https://allnurses.com/nursing-student-assistance/help-preparing-clinical-227507.html)
     
   • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
     
     • use: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
       

[*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking

[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda international nursing diagnoses: definitions and classifications 2009-2011 published by nanda international. cost is $34.99 http://www.nanda.org/marketplace/nandaipublications.aspx
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 80 of the most commonly used nursing diagnoses that you can access for free:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
    

  [*]always sequence actual nursing problems before potential (risk for) or anticipated problems

  • use maslow's hierarchy of needs to sequence the diagnoses in order of priority of importance
    
  • http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs - maslow's hierarchy of needs
    

[*]planning (write measurable goals/outcomes and nursing interventions)

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  
  • improve the problem or remedy/cure it
    
  • stabilize it
    
  • support its deterioration
    
  • how to write goal statements: see post #157 on thread https://allnurses.com/general-nursing-student/careplans-help-please-121128.html
    

  [*]interventions are of four types

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    
    • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
      

    [*]care/perform/provide/assist (performing actual patient care)

    [*]teach/educate/instruct/supervise (educating patient or caregiver)

    [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met) - this is an assessment. you will specifically look for the defining characteristics that supported your nursing diagnoses to see if, or how, they have changed (improved, stabilized or gotten worse) as well as for the evidence of any new nursing problems.

below are weblinks to sites that have information about the nursing process. i suggest that if you like what is on them that you copy and paste it to open documents that you can save because these things sometimes tend to disappear off the internet. the more you look at and read the information the more it sinks in. the beginning chapters of most care plan books also contain information about the nursing process.

• http://home.cogeco.ca/~nursingprocess/index.htm - the nursing process & critical thinking. this is a beautiful site that defines and explains a bit of what the nursing process is. you can also click on the links at the left side of the webpage to go to various subjects included within the nursing process to find out more about them.
  
• https://nursing.advanceweb.com/common/ce/course.aspx?courseid=504&creditid=1 - nursing process - click on the link to "read the article".
  
• http://www.mac.edu/faculty/nursingdepartment/200%20level/nursing_process.htm#return%20to%20top - the nursing process - a short introductory tutorial of what it is
  
• http://www06.homepage.villanova.edu/elizabeth.bruderle/1103/nursingprocess.htm - the nursing process