Master Assessment with Picmonic for Nursing RN

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Planning

Implementation

Evaluation

The Nursing Process

Diagnosis

Assessment

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The nursing process, known by the acronym ADPIE (assessment, diagnosis, planning, implementation and evaluation), is a five-step systematic approach to patient care using the fundamental principles of critical thinking, individualized patient approaches to treatment, goal-oriented tasks, and evidence-based practice recommendations. Assessment, the first step, is where the nurse will collect data about the patient. This information will encompass a health history by accessing the medical record and verbal communication, assessing both objective and subjective data, as well as obtaining diagnostic test results. In a nursing exam, be aware of some key words to alert you that the question is asking you to assess the situation. Examples of these would be terms such as: “identify,” “determine,” and “obtain information.” A nurse should not implement interventions until a complete assessment has been done. Exceptions are only in scenarios where the patient will be at risk of immediate injury or death.

7 KEY FACTS

During the initial assessment phase, the nurse will conduct and document a health history in order to gather data from the patient and/or the patient's family. This includes allergies, current or past medications, surgeries, family health histories, activities, psychosocial behaviors, and nutritIon habits. In doing this, the health care team can collaboratively create a plan that will both address chronic and acute health problems/conditions, and give further information about how to continue and promote health goals.

During the nursing assessment, both objective and subjective data collection are a vital part of the process. Objective data includes measurable and observable data known as “signs.” These include vital signs such as temperature, respiratory rate, heart rate, blood pressure and diagnostic tests. Other observable signs include vomiting, color of skin, bleeding, etc. Lab tests are objective data that aid in the assessment portion of the nursing process, giving more of a comprehensive indication of the patient’s health status.

During the nursing assessment, both objective and subjective data collection are a vital part of the process. Subjective data includes information from the patients perspective or point of view, known as “symptoms.” This data includes feelings, concerns, and level of pain scale.

In nursing, exam questions that are asking you to identify part of the nursing process, there is usually a key word or phrase in the question that should make it easier to know which portion of the nursing process they are asking about. Once you have identified the key word, it will help you understand what the question wants you to answer. In an assessment question, the word “identify” is one of these keywords.

In nursing exam questions that are asking you to identify part of the nursing process, there is usually a key word or phrase in the stem that should make it easier to know which portion of the nursing process they are asking about. Once you have identified the key word, it will help you understand what question wants you to answer. In an assessment question, the word “determine” is one of these keywords.

The nurse must keep in mind that for the most part, assessments are done before interventions take place in order to properly understand how to treat the patient. Remember the acronym ADPIE. “A” comes before “I.” Exceptions are only in scenarios where the patient will be at risk of immediate injury or death.

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