Introduction to Five-step Nursing Process and Assessment

00:01 Hey guys, welcome to the series of ADPIE also known as the nursing process.

00:07 You're going to hear this a lot through your nursing school, and we do this a lot organically as a nurse on the unit.

00:13 But we're going to talk about this process, and how it can help you in your clinical setting? So the first step of ADPIE is nursing assessment.

00:22 And as you guys have been taught nursing assessment is so important in regards to patient care.

00:28 So, we're going to talk about this process, and why it's relevant to you? So let's talk about the nursing process first.

00:35 This is a five-step approach of how you provide care to a client.

00:40 So when we talk about five-steps, it is the A, the D, the P, the I, and the E.

00:47 The ADPIE.

00:49 So we're briefly going to talk about these steps first.

00:52 Just to introduce the nursing process to you.

00:55 And of course, we're going to use a pie image.

00:57 It's only fitting.

00:59 So we're going to use this to discuss our ADPIE concepts.

01:03 So let's take a look at the first piece of the pie called assessment.

01:07 As you all know, this is where we gather information about the client's condition.

01:11 Now, we're going to do this by like a head to toe assessment, for example, gathering information from our patient, the medical records that are available, and even the family members that are around our patients.

01:23 And the assessment piece is the part we're going to focus on today.

01:27 So once we start with our assessment, just explain a process first.

01:31 We use our assessment to decide what the problem is as a nurse.

01:36 Here, we're basically trying to figure out what the priority problem is.

01:41 So we use a common language called a nursing diagnosis.

01:45 It's not a medical diagnosis to use common language.

01:49 So, nurse to nurse, we know what the priority problem is for the patient.

01:54 So, here's an example of this.

01:56 Maybe your patient has an impaired breathing issue.

01:59 So the patient may have a medical diagnosis of pneumonia, but as a nurse, this is not within our scope to diagnose.

02:07 So therefore, we use a nursing common language called nursing diagnosis to discuss the patient issue.

02:15 Next, we're going to make a plan for our patients once we've identified that priority problem.

02:21 So the plan is going to look like a plan of care, goals for our patients, specific actions or interventions, to help improve that patient outcome.

02:30 And also, set some outcomes of where we want our patient to get to and how much better we want them to be.

02:37 So next is what I call the action phase.

02:40 This is the I of the pie, the implementation phase.

02:43 This is where we actually perform those interventions to help improve our patient's condition.

02:50 And lastly, and most importantly, is the evaluation phase.

02:55 This is if where we determine in that planning phase.

02:58 Did we meet these goals, or not? Do we need to change things up? Did those outcomes, were those met? If not, we restart over on that ADPIE process.

03:10 So again, today, we're going to focus on the piece of assessment, the A of the pie.

03:15 So in the assessment process, this is where the nurses are going to gather information, we're going to identify those major health problems that contribute to the patient's overall health and well being.

03:29 So let's talk about assessment.

03:31 Guys, this is a big piece of what we do and a big foundational piece of what we do as a nurse.

03:38 So when you think about assessment, I want you to think that there's a critical thinking approach to this.

03:44 So of course, it's collecting information, but we also have to verify that information, right? It's got to be the right information.

03:52 Then we've got to analyze the information that we have.

03:56 So we're talking about collecting information.

03:59 Who do we collect it from? Well, the best source guys is the client.

04:03 Always, we're going to tell you the best source of information, of course it's the client themselves.

04:08 This could mean from the assessment information we get from the client, or what the client tells us is the issue.

04:15 And our secondary sources, which is our backup or supporting sources is of course going to be the family member that maybe knows the patient really well or lives with the patient.

04:25 The health care providers, and the medical record information.

04:30 Now, once we gather all those primary, secondary sources of information, we've got to actually use our critical thinking skills, and interpret that info, and see how it applies to our patient condition.