Welcome back! Last week we discussed what ADPIE is. During the coming weeks we will delve a little deeper into what each of those parts are. Lets get started!
ASSESSMENT is the basic act of gathering data about your patient. At this stage this has nothing to do with making a plan or even helping your patient in any meaningful way. Yet! Our goal here is to gather as much meaningful DATA as we can. The key here is "meaningful." We can gather a complete history on our patient, but we have to stay focused. Keep your eye on the prize! The prize being a complete history and physical in a timely manner. The patient will of course wander aimlessly in their description as to why they are in the hospital or clinic that day. You have to keep your patient focused. As the nurse, help the patient, and I mean this in the nicest way possible...get to the point.
You must get them to tell you why they came into the health care setting THAT DAY. This is especially true if you work in the ER or urgent care. If you are inpatient and the patient has been in the hospital for a while, THEN, you can gather more than what would normally be considered necessary.
Most healthcare settings will have a standard form for your facility or floor to gather information. Use that if you can. It has been specifically developed for your unit and will help you provide the most important information to the primary care professional. If you do not have something on your floor or facility, you are in luck! We have a tool to help you get the gist of gathering assessment data.
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You may not use all of the form. Our co-founder David, made it during his time in school and found it very helpful.
When you have time, you need to do thorough assessments on your patients; however, focused assessments are most often the best way to go. This quick assessment style will hit all the major highlights of your patient's conditions and you won't miss anything. This usually looks like:
Neuro
Cardiac
Respiratory
Genito/Urinary
Gastrointestinal
Skin
Musculoskeletal
Psych-social
Other
We will go deeper into all of these in the coming weeks, but you need to hit those major systems in order to make sure you have done an effective assessment on your patient.
We would like to note that if your patient is not able to speak for themselves (English as a second language, altered mental status, comatose, minors, et cetera) you must work with them as best a possible. Your facility should have a standard way of addressing language barriers with some kind of interpretation service. Defer to the parents for your minor populations. Family is usually a good source as well for any of these patients. It really is case-by-case, but your nursing program or health care facility should help you differentiate them.
Next week we will be covering DIAGNOSIS, which takes the information we gathered and turns it into something we as nurses can use to better care for our patient. Follow this link here, to read it!
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