Adpie Nursing Documentation

ADPIE: the process in which a NURSE provides care in his/her role to an INDIVIDUAL patient/client, based on the needs of the patient related to a specific medical diagnosis. Assessment Data collection: Generaloverall collection of information Focusedrelating to specific area of the body or dx (respiratory, integumentary, etc.) SUBJECTIVE: direct from patient or family/spouse OBJECTIVE: what you SEE, HEAR, SMELL, FEEL -reason for present assessment -history of current complaint (previous symptoms and treatment) -vital signs (including pain) -head to toe (all systems) -hearing -vision -vaccinations/immunizations -work/employment -social (drinking, drugs, sex, sexual preference, etc.) -travel -education/literacy level -family (illnesses present, past) -medications (which, how often, how long) -lab results -patient questions or concerns Nursing Diagnosis Actual or At Risk For based on the Medical Dx combined with the assessment data Plan The goal you have related to the Nursing Dx and by when it will occur. Generally there will be many. For your RUA there will be three. Implementation/ Interventions The actions you as the nurse will perform to help meet the goal. Evaluation How your interventions are working toward your goal. Begins as soon as you start an intervention. NDX-Pain RT-Must be related to the Med Dx in some way: recent surgery or fall AEB-the item of present concern: verbalized pain of 9/10 Focus: Outcomes, Safety, Education, etc. -client will not fall during entire stay at facility -client wound will not become infected during healing process -client will correctly perform hand hygiene by the end of today -provide education: to client and/or care team -treatments: ordered or request for -medications: ordered or request for -clinical team (PT, OT, Social Work, Aides, etc): already involved or request -monitor for changes of original assessment -how is the client responding to each intervention -what are the outcomes of each intervention -should you change the intervention? -was the goal met? -did the dx reoccur? Documentation occurs at the end (as appropriate ) to record all the above. Nursing Process ABCs Safety Maslow’s hierarchy of needs -physiological, safety, intimacy/relationships, feeling accomplished, use full potential Dehydration: -less urine output, dry skin, skin tenting, dry mucus membranes, fatigue, dizziness, headache -UTI, concentrated urine, constipation, confusion, low BP/orthostatic hypotension, rapid HR BP up, HR down and vice versa (at a fundamental level-this will change with dx complexity) Liquid vs Clear Liquid: pudding and milk shake vs broth and gelatin NPH air to Regular air-draw Regular (short acting)-to NPH (intermediate or long acting) and draw up Ice to reduce inflammation and assist clotÝng Heat to soothe discomfort and remove bruising Enteric coated-for EITHER for slow/extended release OR protect stomach lining type depends on client dx Every 2 hours is max for checking to void and positioning Oxygen low flow nasal, higher flow requires humidification Delegation requires ability to perform task appropriately/safely Airway issue-client will be restless and agitated Aspiration precaution: 30-45 degrees or higher (semi fowlers or higher) Sterile technique: don’t lean over field, don’t turn back on field, don’t touch anything after sterile gloving Hand hygiene: wet, warm water, 5ml soap, make bubbles, friction, rinse, dry Personal Protective Equipment: gloves on last…off first Reposition client first… Meet needs without meds first… milli- move decimal point 3 times… 1kg = 2.2lb (k first in alphabet before l) 3 and 5 are your magic numbers: 5ml=1tsp 15ml=1Tbsp (3 x 5ml) 30ml=2Tbsp 30ml=1oz 240ml=1cup (3 x 8oz) PAIN assess every encounter with patient. Who: is having the pain? age, sex, situation, dx? What: is the pain level? Where: is the pain located? When: did the pain begin? Why: did you begin having pain? trauma? Misuse? How: do you relieve your pain? have you treated the pain in the past? Begin intervention with non-pharmacologic measures. Administer medication as ordered. Return to re-assess pain after interventions. DOCUMENT all of the above.