Adpie for exam - Lecture notes 1-8 PDF

Preview

Summary

ADPIE examples for exam questions asking to explain answer using ADPIE...

Description

ADPIE EXAMPLES! IDC Assessment ! - Bladder assessment on admission! • Check bladder volume- should not exceed 500ml! • Note signs and symptoms indicating full bladder! - When did pt last void- if pt has not voided 4hrs post op or admission they may need a catheter to closely monitor output post surgery ! - Determine Pt normal pattern of voiding and frequency ! - Appearance of urine! - Identify urinary problems (urinary obstruction, retention) and factors effecting the elimination patterns ! DiagnosisPlanning - Maintain normal urinary elimination ! • Promote fluid intake to ensure intake/output within normal range ! • Prevent infection such as UTI! - Maintain skin integrity - prevent moist skin and pressure ulcers! - Manage urinary incontinence ! • Bladder training ! • Pelvic floor exercises ! Implementing ! - Strict FBC to monitor intake and output! - Encourage fluids to prevent urinary stasis! - Perineal care- ensure site remains clean, check for signs of infection (foul smelling, cloudy)! - Check there’s no occlusions or kinks ! - Empty bag every shift ! - Educate Pt- don’t pull on catheter, keep urine bag lower than bladder! Evaluate - Involves assessing the Patients current status in relation to outcomes.! - Has the Patients FBC improved- is output and intake within normal ranges! - Is urine clear? Pain reduced> !

Palliative Care Assessment ! Assess behaviour status by asking questions such as! - Are you able to independently do ADL’s?! - Do you have difficulty shopping, cleaning, cooking?! - Are you able to mobilise by yourself or do you require assistance?! Assess their social status- have you withdrawn socially? Who is your support network?! Assess phycological status ! - Do you feel lethargic / low energy levels? ! - Do you feel anxious about your prognosis? ! Other questions make include! - Do you have difficulty sleeping?! - Do you have an end of life plan, wish to die at home or? ! - Do you have any coping mechanisms such as prayer, rest ect.?! - What is important to you?! Diagnosis - medical diagnosis, nursing diagnosis - symptoms !

Planning - Maintain functional status ! - Improve well being ! - Prevent social isolation ! - Maintain skin integrity ! - Maintain hygiene, body image and self esteem ! - Enhance patient comfort through pain management ! - Attend to special needs ! Implementing !

Mobility 1.Assistance x1 1.Encourage Range of Movement

Rationale To prevent falls and promote safety when mobilising Helps keep muscles in current strength (prevent muscle wastage) and promote circulation

Hygiene 1.Daily shower and pm wash 1.Hair and nail care

To assist with self-esteem and maintain hygiene and self care To maintain dignity and body image

Elimination 1. Check BO daily. Intervene if BNO x3/7 2. FBC

To maintain bowel function To manage input and output

Skin Integrity 1.Braden Score 1.Encourage changing position 2hrly Comfort

To assess patient risk of pressure sores To prevent prolonged pressure in one area and prevent ulcers.

1. R.I.B

To conserve energy and prevent lethargy

2. Heat/ice pack/massage

To relax the pt and reduce pain

Phycological Support 1. Set up a schedule for family/ friends visits 2. Reassure patient- speak calmly

To prevent social isolation and loneliness Reduce anxiety and stress

Observations 1. Vital signs to assess haemodynamic status 2. Pain score holy

Show deterioration or changes in status To assess level of pain and need for more analgesia

Treatments 1. Analgesia

To reduce pain

2. Medication prior to nursing activities

To promote participation in activities and reduce pain

Diet & Hydration 1. Refer to speech pathologist to assess swallowing / implement safe diet 2. Dietition review

To prevent aspiration and improve oral intake

Improve nutritional status

Respiratory Needs 1. Suction 2. High flowers / breathing coughing techniques Specific Education 1. Address concerns about end of life 2. Educatie/support family Special Needs 1. Be available to listen to feelings about illness and death 2. Refer to spiritual advisor, encourage chapel service attendance, encourage use of spiritual resources, allow time and privacy for prayer

Respect and recognising spiritual needs ! May assist patient with finding meaning in death, redefining hope, remaining at peace.

Evaluating - Has the patients mental status improved? Is their anxiety still causing them trouble, are they still fearful of dying. - Is the patients needs being met…

Pain Assessment - COLDSPA! - HIPPA! 1. Determine if acute or chronic ! 2. Location- can you point to the site of discomfort? Mark it on the chart.! 3. Pain intensity- can you rate your from 0-10, 0 being no pain, 10 worst pain?! 4. Pain quality- what does it feel like, can you describe it to me. ! 5. Pattern- when did it begin, does it reoccur, how long are the intervals without pain?! 6. Precipitating factors- does anything trigger your pain?! 7. Alleviating factors- what makes the pain better?! 8. Associated symptoms- what else occurs with the pain?! 9. Effect on ADLS- how does it impact your sleep, concentration, mood?! 10. Coping resources- what strategies to you use to releive the pain?! 11. Affective responses- how does impact your mental status?! 12. Observe behaviours - teeth clenching, guarding, facial expressions, confusion ! Diagnosing ! Acute or Chronic, Location of pain, other associated factors !

Planning - Reduce pain! - Improve ability to do ADL’s! - Improve mood and affect ! - Establish effective coping mechanisms ! - Identify and eliminate preceding factors ! Implementing ! Pharmacological- Opioids, narcotics, pre medicate before actives to prevent pain before it occurs !

Non-pharmacological interventions ! - body: massage, heat/cold! - mind: relaxation,, distraction, info about pain- reduce stress ! - Spirit: prayer, meditation, rituals! - Social interactions: communication, family therapy, volunteering, support groups! Educate- Reducing fear and anxiety- relieve strong emotions capable of amplifying pain, give Pt opportunity to talk about their perception and reaction to the pain. Provide accredited info, clarify expectations to minimise anger, answer any Q’s and concerns. ! Diary or flow sheet used for chronic pain- eg. Weekly log with activities, pain onset, times of day, treatments! Evaluate Using goals identified in planning stage, collect data and evaluate effectiveness of interventions and whether or not they satisfy the goals. ! - Determine effectiveness of pain management - Did it resolve their pain, did the pain score drop, is the Pt more comfortable ! - Is Pt receiving adequate support?! - Has Pt physical condition changed?! - Is adequate analgesia being given? Would Pt benefit from change in dose?! - Modify/update care plan accordingly ! - Handover!...