Case Study of ADPIE: Assessment (Nursing)

00:01 Welcome to the application of the ADPIE otherwise known as the nursing process.

00:06 So, if you guys recall, there's a five-step nursing process that we use called ADPIE.

00:13 This means to assess, diagnose, plan, implement, and evaluate our patient's plan of care.

00:20 So just to recall a few pointers on each one of those pieces of the pie.

00:25 So when we're talking about assessment, this is where we gather that patient's information.

00:30 And then we take a diagnosis, which is within our scope of practice, called a NANDA nursing diagnosis to identify a potential or an actual patient problem.

00:41 Then we create a plan.

00:42 And this is going to involve our interventions, or expected goals, and outcomes for our patients.

00:48 And then we have the I piece, which is the action phase, where we implement that plan, and those interventions for our patients to help improve conditions.

00:57 Then, of course, we've got to evaluate here to see if our plan of care was effective.

01:04 Now, we're going to apply this ADPIE piece today.

01:07 And we're going to use a little scenario for you.

01:09 So here we've got Mrs. Dorothy Meyer as our patient. She's 63 years old.

01:14 So the situation today is she fell at home, broke her right hip, and after having surgery to repair the hip, she is now being admitted to our surgical unit.

01:25 So with this scenario here, we're going to walk through that ADPIE process.

01:30 So we're talking about the assessment piece of that pie.

01:33 We use different assessment approaches.

01:36 So we may use our health history.

01:38 This is a really key piece because we're going to gather information to help understand a little bit better our patient's current and past health history.

01:48 Then, of course, we need to put our skills in play with the head to toe physical assessment.

01:53 Now this is really key, as you know in nursing, that we're going to get a great baseline idea of what our patient's condition is.

02:00 We're also going to know any abnormalities we may need to address.

02:05 And lastly, we also use our focused assessment, looking closely at a particular area of concern with our patient situation.

02:14 Now, when we're talking about our health history.

02:16 It's really helpful because this gives us a better understanding, again, of the client's current problems, and some of their past medical history.

02:24 Because sometimes those past medical histories, those are going to come into play with the treatment of your patient when you see them in the hospital.

02:33 So Mrs. Meyer here. She's got a medical history of high cholesterol, otherwise known as hyperlipidemia.

02:40 Also COPD, which is Chronic Obstructive Pulmonary Disease.

02:44 So, she has a lung disease that's chronic.

02:47 Luckily, she does not have to wear oxygen at night currently.

02:51 And also she does live and have some psychosocial support, where she lives at home with her husband in a one story home.

02:58 So we talked about that health history.

03:00 Now, we're going to move to that other assessment approach called that head to toe assessment, as you all may know.

03:06 So, if you remember, when we're talking about assessment, we use our inspection, palpation, percussion.

03:12 We use our ears for auscultation, and we perform a thorough head to toe assessment, and gather data.

03:19 Now, during that assessment, we're going to pick out some other key pieces such as our vital signs we're going to take to include more diagnostic information.

03:28 And right now, Mrs. Meyers oxygen level is at 94% on two liters. So not bad, right? However, when we did our head to toe assessment, many times we're going to communicate with our patient their chief complaint.

03:41 We're also, again, assess our pain score.

03:44 So if you recall, Mrs. Meyers had that hip surgery, So she's reporting her pain at a 7 out of 10 in her right hip.

03:53 Now, just a little refresher.

03:55 If you guys remember, when we're talking about a numeric pain scale, we go from zero being no pain at all, to 10 being the absolute worst pain ever.

04:04 So you can see here, Mrs. Meyers kind of high up on that scale with a 7 out of 10.

04:10 Now physically, we've assessed her and we know she had hip surgery.

04:14 So we see here, that she has a surgical incision with staples on that right upper hip. Again where she had surgery.

04:22 Now, we're going to also bring in that focus assessment piece to continue to gather information.

04:28 With what we know about our health history, we're going to listen and auscultate her lungs.

04:34 So when we listen to Mrs. Meyers, we heard that she had clear lung sounds with a little bit of diminished sounds and her basis.

04:42 Also focus is her surgical incision of course.

04:45 We want to make sure it's free of signs and symptoms of infection.

04:50 So when we assess her we see she has no discharge.

04:53 She has normal swelling or edema that we would note post surgery.

04:57 And some normal redness or otherwise known as erythema that we would again, we would expect all these things post surgery.