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The Nursing Process (ADPIE) | Comprehensive Notes & Study Guide | NANDA Diagnosis, Care Planning

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Master the foundation of all nursing care! This digital guide provides a clear, concise, and comprehensive breakdown of the Nursing Process (ADPIE). Perfect for nursing students in their fundamentals course or anyone preparing for the NCLEX who needs a solid refresher on how to think like a nurse. What’s Inside: Clear Explanations of ADPIE: Step-by-step breakdown of Assessment, Diagnosis, Planning, Implementation, and Evaluation. Nursing Diagnosis Deep Dive: Learn the PES format and the differences between Actual, Risk, and Health Promotion diagnoses with examples. Data Collection Mastery: Understand subjective vs. objective data, primary vs. secondary sources, and how to cluster information. Care Planning Essentials: Guides for writing patient-centered goals, expected outcomes, and appropriate nursing interventions. Prioritization Frameworks: Learn how to use Maslow's Hierarchy to prioritize patient problems effectively.

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Nursing Process Exam Revision Questions
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Questions and Answers

, What are the steps of the nursing process? ADPIE A=assessment D=diagnosis P=planning I=implementation E=evaluation



How does the nurse obtain assessment info? 1- initial (or admission assessment) 2- focused assessment 3- emergency assesment



past medical hx - family hx - reason for admission - current meds - previous
hospitalizations & surgeries - psychosocial assessment - nutrition - complete physical
How does the nurse obtain assessment info? assessment


Collects data about a problem that has already been identified. This type of
assessment determines whether the problem still exists, or any changes.
focused assessment



‐ What are your symptoms?
‐ When did they start?
‐ What activity were you doing ?
focused assessment questions
‐ What makes it better or worse?
‐ What are you doing to relieve the symptom?

Performed to identify a life‐threatening problem (choking, stab wound, heart attack).
Emergency assessment


subjective data Information verbalized or stated by the client.

‐ Observable and measurable information.
objective data ‐ Remember to include your senses: smell, hearing, touch and sight.

sign An objective finding perceived by the examiner ex. (fever, rash, etc.)

Subjective findings verbalized or stated by the client ex. ("I have a headache" " I feel sick in
symptom my stomach.")


signs are objective

symptoms are subjective

2 sources of data primary & 2ndary

primary source of data ‐Information obtained from the patient (only)

‐ Family members
‐ Significant others
secondary sources of data ‐ Past & current health records, laboratory tests,diagnostic procedures, consultations from
other healthcare professionals.


VALIDATE
‐Confirm and verify the information.
collect the data then BLANK the data
‐ Keep it free from errors, bias, or misinterpretation.

Data is 1,2,3 collected, validated, then clustered

defining characteristics which are specific assessment findings that support a nursing
clustering of data often contains diagnosis.


critical thinking is used to analyze and synthesize the information that is collected. The
data is then put into specific clusters that describe a specific client problem.
during the clustering of data what is used


identify sources of data for obtaining subjective & objective, primary & secondary, people, healthcare professionals, medical chart,
information from the client test & lab results etc
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