Nursing process:
ADPIE, Assess, Diagnosing, Plan, Implement, and Evaluate
In each step of the process, the nurse and patient work together as partners, the
patient’s health state and resources influence the patient’s level of participation.
When the patient is an infant or is unconscious or uncooperative, the nurse works
through the steps of the process with the help of a family member or support
person whenever possible.
(1) assess the patient to determine the need for nursing care
(2) determine nursing diagnoses for actual and potential health problems
(3) identify expected outcomes and plan care
(4) implement the care
(5) evaluate the results
Documentation:
If you didn’t document it, then you did not do it
Documentation is the written or electronic legal record of all pertinent interactions
with all the patients: assessing, diagnosing, planning, implementing, and
evaluating.
These records contain data used to facilitate quality, evidence-based patient care,
serve as financial and legal records, help in clinical research, and support decision
analysis.
See chart 19-1 pg. 1173
Vital signs:
The purpose of vital signs are to monitor the functions of the body
Includes: BP, pulse, oxygen, respiration, body temperature, and pain
Normal pulse rate for adults 60-100
Temperature 97.7-99.5 F
BP 120/80
Oxygen Saturation 95%-100%
Pain: OPQRST; pain is the 5th vital sign
Respiration 12-20/min
Comfort and pain:
Pain is one of the body’s defense mechanism that indicates the person is experiencing a
problem
4 P’s: Pain, personal needs, positioning, fall prevention
Analgesic is a pain reliver
Pain is whatever the patient tells you it is
Gate control theory: When you get hurt and you apply pressure or rub the area to
relieve some pain
Acute vs chronic pain
, Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue.
A paper cut that produces sharp pain with a burning sensation is an example of
cutaneous pain.
Deep somatic pain is diffuse or scattered and originates in tendons, ligaments,
bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue
that occurs with a sprain causes deep somatic pain.
Visceral pain, or splanchnic pain, is poorly localized and originates in body
organs in the thorax, cranium, and abdomen. Visceral pain is one of the most
common types of pain produced by disease, and occurs as organs stretch
abnormally and become distended, ischemic, or inflamed
Comfort
Sleep and rest
Because the pain experience is unique to each person, the nurse who wants to help
the patient achieve comfort and pain control needs sophisticated pain assessment
skills.
Hygiene:
Hygiene practices include bathing and care of the skin and specific body areas, including
the oral cavity, eyes, ears, nose, hair, nails, feet, and perineal and vaginal areas.
For patients that are NPO Or intubated provide oral care every 2 hours
Hygiene should be planned in the AM, PM, hours of sleep care and as needed
This also includes changing soiled linens
Infection control:
Some of the most prevalent agents that cause infection are bacteria, viruses, and fungi
Standard precaution: Follow hand hygiene, wear nonsterile gloves when touching
blood, body fluids, excretions or secretions, contaminated items, mucous
membrane, and nonintact skin.
Airborne precaution: Use these for patients who have infections that spread
through the air such as TB, varicella (chickenpox), and rubeola (measles)
è Place patient in a negative pressure room and wear N95 mask
, Droplet precaution: Use these for patients with an infection that spread by large-
particle droplets such as rubella, mumps, diphtheria, flu, pneumonia, and the
adenovirus infection in infants and young children.
è Wear PPE, face mask, and hand wash
Contact precaution: Use these for patients who are infected or colonized by
multidrug-resistant organism, such as MRSA, VRE, and C-Diff
è Hand wash, wear gown and mask
Oxygenation:
Oxygen and carbon dioxide move through the alveoli as part of the oxygenation process
Hypoxia: lack of oxygen going to cells and tissues
è S/S: dyspnea, elevated BP, anxiety, restlessness, confusion, and
drowsiness
è Hypoxia is often caused by hypoventilation
Oxygen is a medication; HCP order is needed
è When there’s oxygen in the room avoid use of nail polish remover, oil,
smoking, and alcohol
è For oxygen therapy always check vital signs and oxygen saturation
è Ordered for patients with hypoxemia, anemia, blood loss
Oxygen therapy
ADPIE, Assess, Diagnosing, Plan, Implement, and Evaluate
In each step of the process, the nurse and patient work together as partners, the
patient’s health state and resources influence the patient’s level of participation.
When the patient is an infant or is unconscious or uncooperative, the nurse works
through the steps of the process with the help of a family member or support
person whenever possible.
(1) assess the patient to determine the need for nursing care
(2) determine nursing diagnoses for actual and potential health problems
(3) identify expected outcomes and plan care
(4) implement the care
(5) evaluate the results
Documentation:
If you didn’t document it, then you did not do it
Documentation is the written or electronic legal record of all pertinent interactions
with all the patients: assessing, diagnosing, planning, implementing, and
evaluating.
These records contain data used to facilitate quality, evidence-based patient care,
serve as financial and legal records, help in clinical research, and support decision
analysis.
See chart 19-1 pg. 1173
Vital signs:
The purpose of vital signs are to monitor the functions of the body
Includes: BP, pulse, oxygen, respiration, body temperature, and pain
Normal pulse rate for adults 60-100
Temperature 97.7-99.5 F
BP 120/80
Oxygen Saturation 95%-100%
Pain: OPQRST; pain is the 5th vital sign
Respiration 12-20/min
Comfort and pain:
Pain is one of the body’s defense mechanism that indicates the person is experiencing a
problem
4 P’s: Pain, personal needs, positioning, fall prevention
Analgesic is a pain reliver
Pain is whatever the patient tells you it is
Gate control theory: When you get hurt and you apply pressure or rub the area to
relieve some pain
Acute vs chronic pain
, Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue.
A paper cut that produces sharp pain with a burning sensation is an example of
cutaneous pain.
Deep somatic pain is diffuse or scattered and originates in tendons, ligaments,
bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue
that occurs with a sprain causes deep somatic pain.
Visceral pain, or splanchnic pain, is poorly localized and originates in body
organs in the thorax, cranium, and abdomen. Visceral pain is one of the most
common types of pain produced by disease, and occurs as organs stretch
abnormally and become distended, ischemic, or inflamed
Comfort
Sleep and rest
Because the pain experience is unique to each person, the nurse who wants to help
the patient achieve comfort and pain control needs sophisticated pain assessment
skills.
Hygiene:
Hygiene practices include bathing and care of the skin and specific body areas, including
the oral cavity, eyes, ears, nose, hair, nails, feet, and perineal and vaginal areas.
For patients that are NPO Or intubated provide oral care every 2 hours
Hygiene should be planned in the AM, PM, hours of sleep care and as needed
This also includes changing soiled linens
Infection control:
Some of the most prevalent agents that cause infection are bacteria, viruses, and fungi
Standard precaution: Follow hand hygiene, wear nonsterile gloves when touching
blood, body fluids, excretions or secretions, contaminated items, mucous
membrane, and nonintact skin.
Airborne precaution: Use these for patients who have infections that spread
through the air such as TB, varicella (chickenpox), and rubeola (measles)
è Place patient in a negative pressure room and wear N95 mask
, Droplet precaution: Use these for patients with an infection that spread by large-
particle droplets such as rubella, mumps, diphtheria, flu, pneumonia, and the
adenovirus infection in infants and young children.
è Wear PPE, face mask, and hand wash
Contact precaution: Use these for patients who are infected or colonized by
multidrug-resistant organism, such as MRSA, VRE, and C-Diff
è Hand wash, wear gown and mask
Oxygenation:
Oxygen and carbon dioxide move through the alveoli as part of the oxygenation process
Hypoxia: lack of oxygen going to cells and tissues
è S/S: dyspnea, elevated BP, anxiety, restlessness, confusion, and
drowsiness
è Hypoxia is often caused by hypoventilation
Oxygen is a medication; HCP order is needed
è When there’s oxygen in the room avoid use of nail polish remover, oil,
smoking, and alcohol
è For oxygen therapy always check vital signs and oxygen saturation
è Ordered for patients with hypoxemia, anemia, blood loss
Oxygen therapy
