The Nursing Process is a patient centered method of caring, that provides a framework to nursing care. This process involves five major steps of Assessment, Diagnosis, Planning, Implement/ Intervention and Evaluation. These steps are known as the “ADPIE”. In this document we will only be focusing on the first two steps which are Assessment and Diagnosis. Nursing Assessment (ADPIE) is the first step in the nursing process. This step can be viewed as an interview process in which the nurse is gathering information from the patient. Observation and asking specific questions are two of the ways a nurse gathers information.
The nurse will have a better understanding of the patient’s psychological, physiological, sociological, and spiritual status. There are many ways this data can be collected. Generally, nurses will conduct a patient interview. Physical examinations, referencing a patient’s health history, obtaining a patient’s family history, and general observation can also be used to gather assessment data. Physiological signs that the nurse would look for would be nerve functions, sleep activity, vital signs, allergies, drug use, chronic condition or any signs of physical abuse.
For psychological, sociological and spiritual understandings, the nurse would look for emotional tone, occupation, family ties, financial support and responsibilities. This information helps the nurse analyze the data collected in order to begin the next step which is nursing diagnosis. Nursing Diagnosis (ADPIE) is the next step in the nursing process. This phase is critical to the nursing process, because it determines what course of treatment the patient will be receiving.
This nvolves making an educated guess which is the overall observation of the nurse’s point of view. Many times there could be multiple diagnoses. This is when the nurse determines actual or potential problems the patient might have which can be determined from the data collected during the assessment. The nurse must be able to organize the data and identify any inconsistencies. Also, must be able to determine risks, strengths and health problems. A nurse cannot diagnose a medical condition, only a physician can, but can identify a potential problem.
In conclusion to the first two steps that was explained in the document. Assessment is a phase that nurses use when they first encounter a patient in any medical facility. This action requires many observation and collection of data. Diagnosis is a phase where you put together all the data and observations to make an educated guess. This phase is also very important because it determines treatment for a patient. These two steps lead to the next three steps of the “ADPIE” which are Planning, Implementation/ Intervention and Evaluation.