Need help with Nursing Process unit

srobb11 · Sep 27, 2011

I'm not really understanding exactly what is giving you trouble. Are you having a hard time remembering the sequence? ADPIE: assessment, diagnosis, plan, intervention, evaluation. If you can remember the sequence, then figuring out what to do is pretty easy. You assess the situation, come up with a diagnosis (this is the hardest, but gets easier with time). Then you make a plan (a goal for the patient relating to the problem), list your interventions to meet that goal and then evaluate to see if it has worked or if you need to make any changes.

A nursing care plan book may help you to sort out the information. It gives you diagnoses, goals you can use related to a particular diagnosis and interventions. You just need to make sure to personalize it to your patient.

Armygirl7 · Sep 27, 2011

Yes! ADPIE

Assessment: Includes objective data like vital signs, and subjective data like Pt states "I got dizzy and fell down the steps,"

Dx: Oh those sometimes baffling Nursing Diagnoses! Definitely get a Nsg Diagnosis book. At my school's Nursing Library we had big Care Plan books - as srobb11 said those are very helpful.

Planning: Goals within a time frame. Goals should be related to what you discovered in your assessment. For example, if you documented 8/10 pain in your assessment then a goal might be: Pt will report reduction in pain level by 1300

Interventions: Should be related to the goals you set - so for example: Administered pain medication as per MD order.

Evaluate: 1300 Pt reports pain 2/10 and states "I feel so much more comfortable." Or if it was a longer term goal like Pt will have bowel movement Q daily and your shift is over before the Pt moves their bowels then I put: Insufficient time to evaluate.

Good luck - and if your Prof returns your completed/corrected Care Plans to you, save them - I found it very useful to have them as a reference throughout Nsg school.

srobb11 · Sep 28, 2011

...and if your Prof returns your completed/corrected Care Plans to you, save them - I found it very useful to have them as a reference throughout Nsg school.

This is great advice.

nique281 · Sep 28, 2011

Thanks Srobb11 and armygirl7. I guess I was freaking out because it was so much information that was presented to us that day. I'm grasping the concept a little better now....just a lot to take in! Thanks for breaking the steps down. The more examples that I read, the more comfortable I feel with the material. Do either of you know of any websites where they have nursing care plans that we can fill out for practice?

Armygirl7 · Sep 28, 2011

I remember doing google searches for care plans and they were never as helpful as a Care Plan book....but try it - just remember to use reliable sources (like .edu, or .org before .coms!)

The thing I found about Care Plans is that they start to make sense and get easier to do the more you do them - but they are ALWAYS time consuming. You can't do them quickly! So give yourself plenty of time.

NCRNMDM, ASN, RN · Sep 28, 2011

I don't know how far you've gotten in lectures, but in my class we've already started lecturing and learning about different illnesses, diseases, and injuries, and how you treat them. What I've found, and what our teacher told us, is that, the more educated you become on treating patients, the more you begin to use the nursing process without realizing it. For example, our teacher gives us scenarios that we work on in small groups during the class. Often, we begin to use the nursing process (ADPIE- assess, diagnose, plan, implement, and evaluate) without realizing we are doing it. At first, the nursing process seemed like a lot of information, but now that we've started implementing it, it makes a lot more sense. Don't get overwhelmed by the information, try to break it down, and study it in small bits. Over time, it will begin to make a lot more sense, and you will find yourself using the process without realizing it at all.