What is the diagnosis phase of the nursing process?

ADPIE is an acronym for assessment, diagnosis, planning, implementation, and evaluation.

The ADPIE process helps medical professionals remember the process and order of the steps they need to take to provide proper care for the individuals they are treating.

This process is essential as it provides a practical and thorough framework for patient care.

It also helps medical professionals develop critical thinking and problem-solving skills.

By following the ADPIE process, medical professionals can improve their work efficiency and promptly develop more accurate decisions.

Process Overview

The purpose of ADPIE is to help improve an individual’s mental, emotional, and physical health through analysis, diagnosis, and treatment.

The ADPIE process allows medical professionals to identify potential problems, develop solutions, and monitor the results individually.

Nurses must reevaluate, adjust and correct the process if it does not improve the patient’s condition.

Here is an explanation detailing each step of the process:

Assessment

Assessment is the first step of the ADPIE process.

During the assessment phase, medical professionals will attempt to identify the problem and establish a database.

Interviewing the patient and family members, observing behavior, and performing examinations help with the assessment.

This step focuses heavily on collecting/recording data, validating information, and listing any abnormalities in the data.

Nurses collect assessment data in one of two ways, subjective or objective.

You cannot measure subjective data directly.

It includes verbal information like asking questions, obtaining verbal feedback, interviewing people, and collecting/gathering a patient’s health history data.

Subjective data is symptomatic because nurses cannot measure or observe it directly.

Objective data is measurable because nurses can see, hear, feel, or smell it.

It includes measuring a patient’s weight, blood pressure, heart rate, and body temperature.

Because objective data is measurable, nurses refer to it as signs.

Gathering as much data as possible during the assessment phase is essential.

While gathering data, Identify if the data is accurate, concise, consistent, and straightforward.

Once you’ve gathered enough accurate data, you can form a conclusion about the patient’s condition.

After that, move on to the next phase of the ADPIE process, diagnosis.

Diagnosis

The process’s diagnosis phase is where the medical professional develops a theory or hypothesis about the individual’s situation based on the information collected while performing an assessment.

Although registered nurses cannot form a professional diagnosis, they can develop critical thinking and communicate their clinical judgments to their team members.

Nurses have a standardized language for communicating their clinical judgments, which comes from NANDA international.

That said, certified nurse practitioners can diagnose medical conditions and act as primary care providers for their patients.

Examples of Medical Language Nurse Use Include:

• Activity intolerance
• Anxiety
• Constipation
• Decreased cardiac output
• Fluid volume deficit
• Hypothermia
• Sleep deficit

The diagnostic process allows medical professionals to decide on the individual they treat.

That determination determines whether the patient is dealing with a physiological, mental, or emotional condition.

And while nurses cannot give a professional diagnosis, they can identify actual or potential medical /health risks.

After performing a diagnosis, nurses must place risks that can cause complications or harm in order.

Organize the highest risks as the top priority (life-threatening).

Accordingly, nurses should label lower risks in descending order (non-life-threatening/minor/future well-being).

Nurses must identify, address and correct new problems that affect other priorities.

Therefore, nurses must perform assessments regularly to approach patient problems adequately.

After identifying and prioritizing the concerns, the next phase of the process is planning.

Planning

Planning involves developing a plan and establishing SMART goals to achieve the desired outcome.

For example, adequate planning helps reduce a patient’s pain or improve cardiovascular function.

SMART goals are specific, measurable, attainable, realistic/relevant, and time-restricted.

SMART goals provide the individual with focused activities designed to improve their condition.

They also provide medical professionals with a plan to measure and evaluate the individual’s improvements.

Goals may be short-term or long-term, singular in nature, and focus on the individual outcome.

Nurses must determine whether the SMART goals benefit the patient.

They must also make sure that the SMART goals are attainable.

In addition to SMART goals, nurses must develop and communicate a care plan and intervention strategies to the team.

It helps maximize the success of the goals.

The care plan involves the steps and strategies needed to achieve the desired goal.

Along with the care plan, developing intervention strategies keeps the individual on track.

Nurses communicate the care plan and intervention strategies to the patient and medical team as part of the treatment.

After nurses establish the care plan, interventions, and SMART goals, they must implement them into patient care.

Implementation

The implementation phase is the actionable part of the process.

It’s where the medical team implements the care plan, SMART goals, and interventions to achieve their goals.

Accordingly, nurses can evaluate and measure this process.

The implementation phase uses a combination of direct care and indirect care.

Direct care involves giving patients physical or verbal aid.

Direct care includes assisting the patient with mobility, performing physical maintenance, range of motion exercises, and assisting with daily living activities.

It may also include coaching, counseling, and providing feedback to the individual.

Indirect care involves actions performed while away from the patient.

Indirect care may include monitoring/supervising the medical staff, delegating responsibilities, and advocating on behalf of the patients.

While implementing the care plan, the nurse/team needs to use critical judgment.

They must also question care plan procedures to ensure it meets the demands/concerns of the people receiving the care.

Steps or procedures that appear inappropriate, non-actionable, or questionable should be questioned and reevaluated with the medical staff. 

Moreover, nurses must communicate with those receiving the care plan to ensure it is safe and aligns with the medical teams/individuals’ goals.

Evaluation

The last phase of the process is the evaluation phase.

It’s where the medical professionals assess and evaluate the success of the planning and implementation processes.

This phase ensures that the individual is making progress towards their goals and is achieving the desired outcome.

Healthcare professionals must evaluate if the process works and identify what brings the individual closer to their goals.

Nurses must reassess the problem if it isn’t working and determine whether it needs to be modified or eliminated.

Nurses must regularly perform evaluations during the ADPIE process to assess the plan and make adjustments.

By performing regular evaluations, medical professionals can determine the appropriate course of action, identify potential errors, and ensure that the process works as smoothly as possible.

ADPIE Recap

The ADPIE process assists medical professionals in identifying and addressing potential medical concerns.

By implementing the process, medical professionals can assess the patient’s condition and ensure they receive adequate care.

The assessment process begins through the collection of subjective and objective data.

This data allows medical to develop a diagnosis based on the collected information.

With the diagnosis, nurses can create a plan with interventions and SMART goals for the patient to follow.

The process is then implemented into action to achieve the plan’s goals.

Nurses must evaluate the process during and after implementation to ensure the individual achieves their goals.

ADPIE is an excellent way to improve critical thinking.

It helps nurses create, evaluate, and reevaluate procedures.

It also helps them implement and modify processes until they reach the desired outcome.

The five stages of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.

In other words, the five stages of the nursing process are ADPIE, which I explained earlier in this article.

Nurses follow these five stages to ensure proper patient care from the beginning of treatment until the end.

Consequently, It allows nurses to utilize a systematic approach to observing, analyzing, taking action, and reevaluating goals, strategies, and outcomes.

Overall this helps nurses perform their best and account for potential mistakes and errors throughout patient treatment.

The ADPIE nursing process is an essential component of clinical care.

It improves critical thinking and decision-making by breaking down processes into simplified and organized steps.

Each concurrent step builds upon the previous one throughout the process until nurses develop and implement a good approach.

With that said, numerous nurses lack experience applying the ADPIE nursing process.

It’s partially due to a shortage of information/resources and busy work schedules making it difficult to implement.

However, new processes are continually developing, allowing current/future nurses to incorporate these processes into their daily work.

Without processes like ADPIE and others, nurses would have more difficulty approaching complex patient care scenarios.

ADPIE isn’t well known among some nurses.

However, there are many well-known, and implemented processes nurses utilize.