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.
The lecture Case Study of ADPIE: Assessment (Nursing) by Samantha Rhea, MSN, RN is from the course Nursing Process – Assessment, Diagnosis, Planning, Interventions, and Evaluation.
What is the fourth step in the five-step nursing process?
The student nurse is getting ready to assess a new client. Which statement by the student nurse indicates the student nurse understands the comprehensive approaches to assessment?
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