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Nursing Process Notes

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Nursing Process
ADPIE
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Assessment
o Gathering Data – from patient, charts, family, etc.
o Subjective
 What the patient says – ex: pain, nausea, dizziness
o Objective
 What you can see – ex. Vital signs, lab values, physical assessment. Think 5
senses if you use one of those it is objective.
o Primary
 From the patient
o Secondary
 From a source other than the patient
Diagnosis
o Analyzing/clustering the data
o Identify NANDA diagnosis – make sure supporting data matches
Planning
o Prioritize
 ABCs – AIRWAY
BREATHING
CIRCULATION
 Maslow’s Hierarchy of
needs
o Delegate
 5 rights
 Person
 Task
 Circumstance
 Communication
 Supervision
 Do NOT delegate TAPE
 Teaching
 Assessment
 Planning
 Evaluation
https://www.registerednursern.com/delegation-nursing-nclex-review/
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Implementation
o What steps you are going to do to help the patient
Evaluation
o Evaluating if your implementations helped or did not help.
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