ADPIE: How To Make The Nursing Process Easy

In nursing school, you will live by two mnemonics. ADPIE and SBAR. If you aren’t already super familiar with these, let me help you out. ADPIE stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation. This is the nursing process. You will use the nursing process for every patient, every time. NCLEX and nursing school test questions will also focus on the nursing process, so it’s all the more important that you understand it to ensure success. I’ll cover SBAR in another post (with a freebie to boot!) so be sure to join my email list and I’ll notify you as soon as it drops!

This will be your mantra throughout all of your clinical rotations.

If your program is anything like mine, you’ll have assignments to complete after each clinical rotation and it will most likely revolve around ADPIE one way or another. ADPIE is essentially just a guide to help you collect the most important information about your patients. I created a one page pdf that you can take with you to clinicals to organize all of your patient information and ensure that you don’t miss anything critical! Let’s break it down.

Assessment

First and foremost, assess your patient! A good assessment is key. If there is anything that you need to master in nursing school, this is it. You will be assessing every patient, every time. And most often, you’ll be doing it several times per shift.

That’s why I dedicated nearly the first half of my ADPIE sheet to your assessment findings. It is organized by body systems so that it can serve as a cheat sheet when it comes to conducting your head to toe assessment.

Lines, Drains, & Airways

Bonus, I also included two boxes for Lines, Drains, and Airways and Medications. I consider these to be a part of my assessment because (you guessed it!) ya gotta assess ’em. You’ll constantly be assessing your lines to make sure they are patent and you can run your meds through them without causing any harm. You’ll be on your drains like stink on you-know-what because anything that’s an ‘out’ needs to be assessed and documented. Airways are of utmost importance because, ya know, oxygen.

Medications

Medications are a paramount assessment for your patients, but it is (unfortunately) often the most overlooked. Any harm that a patient sustains in a hospital is more than likely due to a medication administration error. You are the last line of protection for your patients. It is up to you to know what medications they are currently taking, why they are taking them, and whether or not it is an appropriate therapy. I can’t tell you how many times I have gone through my patient’s Medication Administration Record and found medications that weren’t appropriate for them, or medications that they NEEDED but hadn’t been prescribed. Seriously people. Review your meds. That is all.

Diagnosis

Nowadays, our patients have increasingly complex health issues and generally have multiple, if not several, different diagnoses. It’s really important to know everything that is going on with your patient so that you are able to accurately assess them as well as provide more holistic care.

In the Diagnosis box on the PDF, you’ll want to include medical diagnoses as well as your nursing diagnoses. (This will seriously save you when it comes to writing that care plan later. Wink. Wink.)

Planning

This is the box where you will write down all of your goals for your patient each shift. Is the plan to get your patient up for the first time post-op with PT? Are they waiting for discharge? This is where you collaborate with your interdisciplinary team to figure out what the big picture goals are. Then, you can start making your small picture goals to complement. Example: big picture goal is for the patient to be discharged home in the next day. Small picture goal for your shift would be assessing whether or not the patient is independent in completing their ADLs so that they are discharge appropriate.

Implementation

This is the fun part. What did you do for your patient throughout your shift? Did you start a bolus? Did they complete their physical therapy? This is where you take credit for all of your nursing interventions throughout the shift after making your big and small picture plans. Another helpful hint, if you have identified your nursing diagnoses for each specific patient at the beginning of your shift, it’ll be that much easier to know what goals you need to plan for which will guide your interventions!

Evaluation

This is where you’ll really start to develop that ‘clinical judgement’ that you hear everybody talking about with no clear understanding of where it comes from or how you get it. The more interventions you implement and evaluate in your plan of care, the more you’ll be able to see how they directly affect each disease process in real life. And the better prepared you will be to take care of your next patient.

This last step of the nursing process is always the most rewarding for me. This is where you get to sit back at the end of your shift and ask, “How did my interventions help my patient?” If your patient was hypotensive before the fluid bolus and then normotensive afterwards, you know that the intervention was appropriate and led to a good outcome! If your patient had clear lung sounds prior to the bolus and then became dyspneic with crackles in the bases bilaterally, you know that the patient became acutely fluid overloaded so the intervention was inappropriate.

So, Where’s This Freebie and How Do I Use It?

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