Early in your nursing school experience, you will be introduced to the term “nursing process.” That comes with many acronyms you will memorize to help you with that process. The first and most important one is defined in a recently published book, Nursing Process.
The two book authors, both nurses, provide an in-depth discussion of the nursing process, which was developed more than 60 years ago, to be used as a critical thinking process for professional nurses to provide patient care.
The acronym ADPIE stands for assessment, diagnosis, planning, implementation, and evaluation. These five sequential steps provide the framework for patient care that other healthcare professionals consult and depend on when making critical medical decisions.
The 5 Stages of the Nursing Process
Patient care is frequently changing in this complex world, with new medical breakthroughs and technological advances change the medical care landscape. Also, the population is aging, and with it comes the risk of having life-altering conditions.
By using this concept, the authors of the Nursing Process note that, “In the future, nurses must be able to problem solve in a multitude of situations and conditions to meet these new adversities: challenging nurse-patient ratios, multifaceted approaches to prioritization of care, fewer resources, navigation of the electronic health record as well as functionality within the team dynamic and leadership style.” (Toney-Butler & Thayer, 2020)
Using the ADPIE model, nurses will be able to rise to the challenges and provide the necessary care needed.
Assessment is the first and most crucial step in the nursing process and involves critical thinking skills for obtaining data. According to Nursing World, a journal published by the American Nurses Association (ANA), assessment involves collecting “not only physiological data, but also psychological, sociocultural, spiritual, economic and life-style factors as well.” (“The Nursing Process”, 2021). Data falls into one of two categories: objective or subjective.
This is measurable and observable data like temperature, blood pressure, test results that return specific information, patient’s heart rate, breathing difficulty, height, weight, intake and output, and other similar data. Viewing the patient’s response to pain, such as inability to get out of bed or refusal to eat, how he or she interacts with family members are all helpful observations that are objective and assist in assessing the patient’s needs. In short:
- Physical examination/ assessment
- Measurements (height, weight, vital signs)
- Medical records and previous health history
- Observations of patient behavior
This is data that is not measurable and not observable. This is obtained by talking to the patient, asking questions such as what rate they give their pain level on a scale of 1 to 10. This data involves expressed feelings, emotions, and self-report about a health condition.
This also involves obtaining the patient’s medical history directly from the patient or the patient’s family. In short:
- Patient’s perception of health condition
Electronic health records may play a role in assessment and provide data, both subjective and objective, about a patient’s health condition. General observation of the patient is also a method for assessing patient needs.
Assessment at a glance:
Although nurses do not make a professional diagnosis of whether a patient suffers from a specific disease or medical condition, nurses use critical thinking skills to make clinical judgments they share with the healthcare team members. The North American Nursing Diagnosis Association (NANDA) has an ever-growing list of nursing diagnoses.
According to NANDA, a nursing diagnosis utilizes Maslow’s Hierarchy of Needs, developed decades ago by American psychologist Abraham Maslow. The hierarchy is based on the fundamental needs of all individuals. The gist of it is that the basic needs of one level must be met before the needs of the next higher level can be achieved.
Maslow’s Hierarchy of Needs. An overview of the hierarchy involves a pyramid structure. The lower level needs must be met before the person can move on to the next level.
- Level one: Basic physiological needs. This includes water, food, air, sleep, shelter, exercise, sex, and elimination. These are, as is almost self-evident, the highest priority needs.
In nursing, the concept of ABC (Airway, Breathing, Circulation) belongs in the highest priority category of Maslow’s hierarchy. It plays an important role when it comes to prioritization of care and nursing diagnosis.
- Level two: Safety and security. This means physical safety as well as security of resources. It involves instruction on basic safety while in the hospital, such as guard rails, not getting out of bed without using the call light, the importance of hygiene and washing hands, and fall preventions, for just a few examples.
- It also includes helping a patient feel safe when facing serious medical or surgical issues. The person may have been in an accident and worried about recovery and medical expenses.
- A mother of a newborn may need instructions on keeping her baby safe and the importance of always strapping the baby in its car seat and never leaving the child alone in a car.
- Level three: Love and belonging. Everyone needs to feel accepted by their family and friends. They also need to accept themselves. Nurses foster this by listening to their patients and participating in activities that do not push people away and keep the patient from avoiding social isolation.
- Level four: Self-esteem. To have self-esteem, a person needs to feel useful and self-confident. This is sometimes difficult for a hospitalized patient who feels dependent on others and not useful at all. Nurses can listen to the patients and encourage them to see themselves as integral to the lives of others: their family, their friends, their workplace. For patients who may not return to the workforce, the nurse can garner information about personal achievements. The patient can feel proud and encouraged to feel good about him or herself.
- Level five: Self-actualization. This is the highest level. It cannot be achieved unless all the other levels have been reached. In some cases, this level cannot be reached at all. The nurse’s task is to help patients reach their other goals to reach their maximum potential eventually.
NANDA has developed a standardized language of nursing diagnoses based on the assessments and Maslow’s Hierarchy of Needs. Just a few examples include:
- Ineffective Health Maintenance
- Self- Care Deficit
- Imbalanced Nutrition
- Ineffective Airway Clearance
- Impaired Physical Mobility
- Readiness for Enhanced Nutrition
- Impaired Home Maintenance
- Ineffective Coping
- Activity Intolerance
- Social isolation
- Ineffective Breathing Pattern
The nursing diagnosis forms the basis of the nursing care plan. The plan is put in writing so that other healthcare professionals can do their part in implementing the plan and always act in the patient’s best interest.
Nursing Diagnosis at a glance:
Planning: SMART ADPIE
A nursing care plan is developed based on the assessment and nursing diagnosis. The plan sets SMART goals, which means the goals should be:
- Realistic or relevant
- Timely or time-oriented
For example, a care plan for a patient who has mobility problems may allow them to move from the bed to a chair three times a day and sit in the chair for a certain amount of time.
This is specific, measurable, attainable, realistic, and time-oriented (SMART).
A nursing care plan for a patient who the nurse has diagnosed with a lack of adequate nutrition may have a plan that requires eating several small meals a day instead of three larger ones. Again, the goal is specific, measurable, attainable, realistic, and time-oriented (SMART).
During the planning phase, the nurse determines the patient’s goal and sets priorities for the interventions to reach that goal.
Patients have several nursing diagnoses during their stay. Each of them needs attention; however, prioritizing these helps establish a sequence of care, ensuring most urgent problems are addressed first.
Planning at a glance:
Implementation is the “actionable part of the process.” Implementation provides continuity to patient care. It involves both direct and indirect patient care.
Direct care is when the nurse and other healthcare professionals provide hands-on assistance to help the patient reach their goals. This includes carrying out nursing interventions like administering medication or oxygen, applying a cardiac monitor, or complying with standard treatment protocols. It also involves observation of patients working independently. The nurse provides patients feedback about their progress and discusses changes that need to be made in the care plan for them to meet their goals.
Indirect care involves monitoring the staff to be sure they are working together to carry out the goals of the care plan. Anything that happens in patient care that is done while the nurse is away from the patient is indirect care. Anyone who provides care, either direct or indirect, must document it in the patient’s hospital medical record.
Implementation at a glance:
Evaluation is exactly what it sounds like. The nursing process involves constant monitoring to determine if the care plan is appropriate. Is the patient meeting his or her goals? Are there parts of the plan that seem to be making things worse? If so, they must be discontinued.
The patient should be involved in the evaluation process. If the patient feels a part of the plan is not working, the nurse should listen and either work to adjust the plan or explain to the patient details of the plan and explore how to make it work.
Ultimately, the evaluation part of ADPIE will work to make the whole process run smoothly and keep the patient and the healthcare professionals working together for the good of the patient.
Evaluation at a glance:
Toney-Butler TJ, Thayer JM. Nursing Process. 2020 Jul 10. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29763112.
Potter, P. (2013). Fundamentals of nursing (8th ed.). St. Louis, Mo.: Elsevier Mosby.
Photo: maslow’s hierarchy: plateresca/123RF