Fundamentals
of
Nursing
rnursingnotes rnursingnotes
, The nursing process
''ADPIE''
1. Assessment
Gather information & review
Verify the information collected is clear & accurate
2. Diagnosis
Interpret the information collected
Identify & prioritize the problem through a nursing diagnosis
3. Planning
Set goals to solve the problem
Prioritize the outcomes of care
4. Implementation
Reaching those goals through performing the nursing action
"Implementing" the goals set above in the planning stage
5. Evaluation
Determine the outcome of the goals
Evaluate the patient compliance
Document client's response to pain
Modify & assess for needed changes
, Abbreviations
Abd Abdomen
A.B.G Arterial blood gas DX Diagnosis
ADL Activities of daily living ECG Electrocardiogram
a.c Before meals Fx Fracture
A&O Alert & Oriented h.s At bedtime
BP Blood pressure HOB Head of bed
dc Discontinue HOH Hard of hearing
H&H Hemoglobin & Hematocrit H&P History & physical
DNR Do not resuscitate HR Heart rate
ICU Intensive care unit PO By mouth
I&O Intake & output p.r.n As needed
IM Intramuscular ROM Range of motion
IV Intravenous S&S Signs & Symptoms
NGT Nasogastric tube Stat Immediately
NPO Nothing by mouth U/A Urinalysis
CPR Cardiopulmonary VS Vital Signs
PPE Resuscitation PERRLA Pupils equal, round,
Personal Protective reactive to light &
Equipment accomodation
of
Nursing
rnursingnotes rnursingnotes
, The nursing process
''ADPIE''
1. Assessment
Gather information & review
Verify the information collected is clear & accurate
2. Diagnosis
Interpret the information collected
Identify & prioritize the problem through a nursing diagnosis
3. Planning
Set goals to solve the problem
Prioritize the outcomes of care
4. Implementation
Reaching those goals through performing the nursing action
"Implementing" the goals set above in the planning stage
5. Evaluation
Determine the outcome of the goals
Evaluate the patient compliance
Document client's response to pain
Modify & assess for needed changes
, Abbreviations
Abd Abdomen
A.B.G Arterial blood gas DX Diagnosis
ADL Activities of daily living ECG Electrocardiogram
a.c Before meals Fx Fracture
A&O Alert & Oriented h.s At bedtime
BP Blood pressure HOB Head of bed
dc Discontinue HOH Hard of hearing
H&H Hemoglobin & Hematocrit H&P History & physical
DNR Do not resuscitate HR Heart rate
ICU Intensive care unit PO By mouth
I&O Intake & output p.r.n As needed
IM Intramuscular ROM Range of motion
IV Intravenous S&S Signs & Symptoms
NGT Nasogastric tube Stat Immediately
NPO Nothing by mouth U/A Urinalysis
CPR Cardiopulmonary VS Vital Signs
PPE Resuscitation PERRLA Pupils equal, round,
Personal Protective reactive to light &
Equipment accomodation
