The Nursing Process (ADPIE)

The nursing process is how you turn a patient's presentation into a plan and then act on it, the same disciplined way every time. Ida Jean Orlando began shaping it in 1958, arguing that the patient's behavior sets it in motion: you read the behavior, analyze it, and determine what the patient needs. It runs on critical thinking, a patient-centered approach, evidence-based practice (EBP), and clinical intuition, in five steps: assessment, diagnosis, planning, implementation, and evaluation (ADPIE).

What is the Nursing Process?

The nursing process is a systematic, rational method of planning that guides all nursing actions toward holistic, patient-focused care. It is scientific reasoning applied at the bedside, and it takes critical thinking to do well.

Purpose

• Identify the client's health status and actual or potential problems (through assessment).
• Build plans to meet the identified needs.
• Deliver specific interventions to meet them.
• Apply the best available evidence and promote human function and response to health and illness (ANA, 2010).
• Protect nurses legally when the standards of the process are followed correctly.
• Keep your practice systematically organized.
• Build a database of the client's health status, concerns, response to illness, and ability to manage care.

See also: The Nursing Process Quiz (10 Questions)

Characteristics

• Patient-centered. Care that respects and responds to the individual's needs, preferences, and values. You advocate for the patient's informed decision-making.
• Interpersonal. A therapeutic relationship where nurse and patient respect each other and work toward a shared goal.
• Collaborative. It works across nursing and interprofessional teams through open communication and shared decision-making.
• Dynamic and cyclical. Each phase interacts with and influences the others.
• Requires critical thinking. The skill that lets you identify problems and choose interventions that work.

The Five Steps

The five steps are assessment, diagnosis, planning, implementation, and evaluation, remembered as ADPIE. Learn them step by step; with experience you will move back and forth among them. They are not separate boxes but overlapping subprocesses.

1. Assessment: "What data do you collect?"

Assessment is collecting, organizing, validating, and documenting the client's health status. When you first meet a patient, you assess to identify health problems and their physiological, psychological, and emotional state, and to build a database of how they respond to illness and manage their care. It takes critical thinking.

Collecting Data

Data collection is gathering information about the client's health status. Keep it systematic and continuous so nothing important is missed. The best way is a head-to-toe assessment.

Types of Data

Data is objective or subjective, and also verbal or nonverbal.

• Objective data (signs). Measurable, observable data collected through the senses and compared to a standard: vital signs, intake and output, height and weight, body temperature, pulse, respiratory rate, blood pressure, vomiting, distended abdomen, edema, lung sounds, crying, skin color, diaphoresis.
• Subjective data (symptoms). Covert information only the patient can verify: nausea, pain, numbness, pruritus, attitudes, beliefs, values, and how they perceive the health concern and life events.
• Verbal data. Spoken or written statements from the client or a secondary source. Listen for slurring, tone of voice, assertiveness, anxiety, word-finding difficulty, and flight of ideas.
• Nonverbal data. Behavior that sends a message without words: body language, general appearance, facial expression, gestures, eye contact, proxemics (distance), touch, posture, clothing. It can be more telling than words when the body language does not match what the patient says.

Sources of Data

Data comes from primary, secondary, and tertiary sources. The client is the primary source and the only one who can give subjective data; anything the client reports is primary. Secondary sources sit within the client's frame of reference but come from someone else: family or significant others (especially when the client cannot speak for themselves or is a child), the client's records, and assessment data from other members of the team. Tertiary sources sit outside the client's frame of reference, such as textbooks, nursing journals, drug handbooks, and policy manuals.

Methods of Data Collection

The three main methods are the health interview, physical examination, and observation.

The health interview is the most common approach, a purposeful conversation to gather or give information, identify shared concerns, evaluate change, teach, or provide support. The nursing health history, part of the admission assessment, is one example. Patient interaction is heaviest during assessment, so this is where you build rapport.

The physical examination, along with the patient's health and family history and general observation, gathers the rest of the assessment data. A thorough physical assessment leads to a more accurate diagnosis, better planning, and better interventions.

Observation uses all five senses to learn about the client's appearance, functioning, relationships, and environment. Nurses observe mostly through sight, but the other senses matter too: smelling foul odors, auscultating lung and heart sounds, and feeling the pulse and skin.

Validating Data

Validation verifies that data is accurate and factual. Double-checking lets you confirm findings, compare objective and subjective data, and avoid jumping to conclusions without enough support. For example, a reading of 210/96 mmHg in a client with no history of hypertension should be retaken, possibly with different equipment or a second person. A client's report of "feeling hot" should be checked against an actual temperature. Vague statements should be clarified: if a client says she has had pain "on and off for 4 weeks," ask her to describe what the pain is like and what "on and off" means. Validation also means distinguishing cues from inferences. Cues are what you can directly observe (what the client says, or what you see, hear, feel, smell, or measure); inferences are your interpretation of those cues. Observing that an incision is red, hot, and swollen is a cue; concluding that it is infected is an inference.

Documenting Data

Once collected, data is recorded and sorted. Good record-keeping is fundamental so the whole team can access the information and reference it during evaluation.

2. Diagnosis: "What is the problem?"

The second step is the nursing diagnosis. You analyze the gathered data, identify health problems, risks, and strengths, and write diagnostic statements about the patient's actual or potential problems. More than one diagnosis is sometimes made for a single patient. Using clinical judgment to formulate the diagnosis is what makes the planning and implementation that follow effective.

3. Planning: "How to manage the problem?"

Planning gives direction to nursing interventions. Once the nurse, the supervising medical staff, and the patient agree on the diagnosis, the nurse plans a course of treatment with short and long-term goals. Each problem gets a clear, measurable goal tied to an expected outcome. Goals and outcomes are formulated from evidence-based practice guidelines, and the nursing care plan is the tool that organizes them. Care plans tailor care to the individual, account for the overall condition and comorbidities, and improve communication, documentation, reimbursement, and continuity of care.

Types of Planning

Planning starts at the first client contact and continues until the nurse-client relationship ends, ideally at discharge.

Initial planning is done by the nurse who completes the admission assessment, usually the same nurse who creates the first comprehensive care plan.

Ongoing planning is done by every nurse who works with the client. As you gather new information and see how the client responds, you individualize the plan further. Ongoing planning at the start of a shift lets you check whether the client's status has changed, set priorities for the shift, decide which problem to focus on, and coordinate so more than one problem is addressed at each contact.

Discharge planning anticipates needs after discharge. Start it when the client is admitted, involve the client and their family or support persons, and collaborate with other professionals so biopsychosocial, cultural, and spiritual needs are met.

Developing a Nursing Care Plan

A nursing care plan formally identifies existing needs and recognizes potential needs or risks. It supports communication among nurses, patients, and other providers and keeps the quality and consistency of care from being lost.

4. Implementation: "Putting the plan into action"

Implementation is when you put the treatment plan into effect: the actual carrying out of the interventions in the care plan. It usually begins with any needed medical interventions. Interventions should be specific to the patient and focused on achievable outcomes, and include monitoring for change, direct care, tasks like medication administration, patient education, and followup. The Nursing Interventions Classification (NIC) taxonomy, developed by the Iowa Intervention Project, lets you look up a diagnosis and see which interventions are recommended.

Nursing Interventions Classification (NIC) System

There are more than 550 nursing intervention labels, grouped into seven classes.

Behavioral interventions help a patient change behavior: teaching stress and relaxation techniques, supporting smoking cessation, or engaging the patient in activity like walking to reduce anxiety, anger, and hostility.

Community interventions take a community-wide approach to health behavior change: running an education program for first-time mothers, promoting diet and physical activity, starting HIV awareness and violence-prevention programs, or organizing a fun run for breast cancer research.

Family interventions affect the patient's whole family: a family-centered approach to limit the spread of a communicable disease, supporting a nursing mother with breastfeeding, or teaching family members how to care for the patient.

Health system interventions keep the facility safe for patients and staff: following infection-control procedures and keeping the patient's environment safe and comfortable, such as repositioning to avoid pressure ulcers.

Physiological interventions address the patient's physical health and are either basic (hands-on care from feeding to hygiene) or complex (such as inserting an IV line to rehydrate a patient).

Safety interventions prevent injuries: teaching a patient how to call for help if they cannot move safely on their own, or how to use a walker or cane and shower safely.

Skills Used in Implementing Care

Implementing care takes cognitive, interpersonal, and technical skills. Cognitive (intellectual) skills cover the underlying knowledge (basic sciences, procedures and their rationale) plus problem-solving, decision-making, critical thinking, clinical reasoning, and creativity. Interpersonal skills are how you relate to and communicate with the patient and team, which largely determines whether an action works. Technical skills are the hands-on procedures: changing a sterile dressing, giving an injection, handling equipment, and moving, lifting, and repositioning clients safely.

Process of Implementing

1. Reassess the client. Before acting, confirm the intervention is still needed, since the client's condition may have changed even if the order is already written.
2. Determine the need for assistance. You may need help, for example to ambulate an unsteady obese client, reposition a client, or apply unfamiliar traction equipment for the first time. Some tasks may also be done by LPNs/LVNs or unlicensed assistive personnel (UAP).
3. Implement the interventions. Explain to the client what will be done, what sensations to expect, what they should do, and the expected outcome. Interventions are independent (routine tasks a nurse can do alone, like checking vital signs or teaching medication use), dependent (requiring a physician's order, like prescribing medication, inserting or removing a urinary catheter, or ordering a diet), or interdependent (collaborative work across disciplines, such as a postsurgical recovery plan combining a physician's medication, a nurse's feeding assistance, and a physical or occupational therapist's treatment).
4. Supervise delegated care. Delegate appropriately, considering each team member's capabilities, while retaining accountability for the outcome. Registered nurses cannot delegate nursing judgments; assessment and evaluation of the impact of interventions cannot be handed to unlicensed personnel.
5. Document the activities. Record what was done and how the patient responded, precisely and concisely.

5. Evaluation: "Did the plan work?"

Evaluation is the final step and is vital to a good outcome. After the interventions are carried out, the team reassesses to see whether the desired outcome was met. Outcomes are generally described in three ways: the patient's condition improved, stabilized, or worsened.

Steps in Evaluation

1. Collect data. Gather both objective and subjective data so you can draw conclusions about whether goals were met, and document it concisely.
2. Compare data with desired outcomes. The goals in the care plan are the standard. A goal is met when the response matches the desired outcome, partially met when a short-term outcome was reached but the long-term goal was not (or the goal was incompletely attained), or not met.
3. Analyze the client's response relative to nursing activities. Determine whether the nursing activities actually related to the outcome, successful or not.
4. Identify factors contributing to success or failure. Collect more data to confirm why the plan worked or did not. A supportive or unsupportive family, or an uncooperative client, can change the result.
5. Continue, modify, or terminate the care plan. The process is dynamic and cyclical. If goals were not met, it begins again from assessment, with the plan adjusted to new data. As clients meet goals, new ones are set; where goals remain unmet, evaluate why and revise the plan.
6. Plan for discharge. Discharge planning transitions the patient to the next level of care with individualized instructions, improving quality of life by ensuring continuity of care with the family or other providers.

The Agency for Healthcare Research and Quality describes IDEAL discharge planning: Include the patient and family as full partners; Discuss the five key areas that prevent problems at home (what life at home will be like, medications, warning signs, test results, and followup appointments); Educate in plain language throughout the stay; Assess understanding with teach-back; and Listen to and honor the patient's and family's goals and concerns. A discharge plan documents the equipment needed at home, dietary needs, medications (purpose, dose, how to take, side effects), key contact numbers, danger signs and emergency response, home-care activities to do or avoid, and a summary of the condition and followup.