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Using ADPIE Within the Nursing Process

Written by John C.

Introduction

The acronym ‘ADPIE’ - which stands for assessment, diagnosis, planning, implementation, and evaluation - is used within the field of nursing to help guide the proper process of treatment provision for patients (Bernard, 2018). This process can be used in either physical or mental health settings, and follows the same process regardless of what branch of medicine clinicians are working in (Ibid.). This essay will introduce Jerry, a patient with possible alcohol issues, who is a 68 year old man whose drinking has become concerning to his friends and family, and whose memory has been said to be getting rapidly worse. It is of note here that in line with the Nursing and Midwifery Council’s Code (NMC, 2015), ‘Jerry’ is a pseudonym to maintain patient confidentiality, and no other personally identifiable information shall be used in this essay. In order to demonstrate the ADPIE process, each stage shall be outlined below; decisions and actions shall be supported both by clinical guidelines and by peer reviewed evidence was relevant.

 

The ADPIE process

The first stage, assessment, is a crucial phase of the ADPIE process (Bernard, 2018). The assessment of Jerry’s potential issues with alcohol shall consist of a two-staged approach. Firstly, a conversation shall be held between nurse and Jerry (and his wife, if present). This will utilise a motivational interviewing approach and will probe for his attitudes around alcohol use, and his beliefs in relation to this. It will provide the nurse with a overview of Jerry’s level of insight and current stage of motivation to effect change in relation to this issue (Kleban, 2009). The use of motivational interviewing not only allows for these insights, but also engenders a collaborative approach to care, which will drive engagement and future treatment adherence (O’Neill and Nicholson-Cole, 2009). The second phase of the assessment process sees the introduction of the AUDIT measure to screen objectively for alcohol misuse and/or dependence (Saunders et al., 1993). This measure is recommended by NICE as an inexpensive and highly sensitive means of screening for and identifying alcohol misuse disorders (NICE, 2011). This is a relatively quick process, and can allow for additional supportive conversation to take place in a person centred manner; Jerry’s score on the AUDIT is 21 points; this will be discussed below. Regarding the potential memory issues that Jerry is reported to be demonstrating, this can be assessed through the same conversation above, and issues can be explored in a collaborative and supportive manner. At first, Jerry appeared reluctant to discuss his memory loss, but the use of the motivational interviewing approach, which is particularly effective in working around resistance (Kleban, 2009), enabled him to eventually feel comfortable discussing this. He identified occasions of complete  loss of memory, and agreed to take the mini mental state examination (MMSE: McDowell et al., 1997). This is a recommended tool for screening patients who are considered to be at risk of developing dementia (NICE, 2016); Jerry scored 24 during his assessment.

 

The next stage is diagnosis, which is informed by a detailed process of assessment as described above. The objective tools used - the AUDIT and MMSE - allow for this process to be carried out within conjunction with clinically meaningful measures (NICE, 2011; 2016). By utilising a supportive clinical interview throughout the assessment process, wide cues about Jerry’s issues could be appraised and processed to inform his diagnoses. From talking to Jerry it was clear that a vast deal of his routine revolves around drinking, and if alcohol is not at hand for whatever reason, he quickly becomes abusive and distressed. His score of 21 on the AUDIT measure suggests that his use of alcohol is both hazardous and harmful (Saunders et al., 1993). As a result of this information, Jerry could be subsequently diagnosed as being alcohol dependent. Regarding Jerry’s memory, the clinical interview pointed towards there being an increased frequency of memory lapses being experienced, which combined with the MMSE score of 24 indicates that Jerry is currently living with mild depression (McDowell et al., 1997). Due to Jerry’s prolonged and acute miss of alcohol, an initial diagnosis related to this dementia is likely to be Korsakoff Syndrome. Although there is no validated test with which this diagnosis can be confirmed, the factors of Jerry’s presentation would support this clinical judgement being made (Alzhemiers, Association, 2016).

 

Following the diagnosis comes the planning, implementation and then evaluation phases. For the purposes of continuity of problem, this triumvirate of phases shall first be discussed in relation to Jerry’s issues with alcohol, and then subsequently with his dementia.

 

Regarding Jerry’s alcohol dependence, he was reluctant to completely cease his use of alcohol. Although NICE guidelines (2011) identify this as a key treatment goal, they also state that an important first step is to cut dow alcohol intake in a structured way. We therefore plan with Jerry to reduce his intake to around 4 units of alcohol a day, whilst also accessing specialist alcohol services to deal with the issue in the long term. In the interim, we also plan that he should call a specialist helpline if and when he feels the need for support whilst cutting down. To implement this plan, it is important that Jerry’s motivation is harnessed before it decreases, as can often be the case (Robinson et al., 2016). This will be aided by Jerry’s goal of cutting down rather than abstaining, for this represents a more manageable and realistic goal, which in the short term is likely to boost motivation and increase levels of self-efficacy: both important factors in the process of recovery (Maisto et al., 2015). It is also important that in order to maintain progress, rapid referral and treatment by specialist services is implemented. To evaluate these goals, a date for follow up in four weeks time shall be set. The AUDIT measure will again be used to measure Jerry’s alcohol intake in relation to our set goals. It is anticipated that following an urgent referral to specialist services, Jerry would also have had an initial season with alcohol workers within this timeframe. The follow-up appointment will also allow for further risk assessments as to Jerry’s condition to be made.

 

The next area of consideration is the planning, implementation and evaluation with regards to Jerry’s possible Korsakoff’s Syndrome diagnosis. His MMSE score suggests that although symptoms are currently classified as mild, they will degenerate and get worse over the passage of time (Rensen et al., 2017). Although Jerry found this difficult to talk about, with the support of his wife he noted the importance of being able to implement supportive structures for this condition. As a result we planned to address two goals, the first will be to develop a system to support better self care, and the second was to access specialist treatment as soon as possible. To implement this, Jerry and his wife will identify areas of self care and activities of daily living which are currently being forgotten by Jerry. A checklist can then be drawn up and hung in a prominent place in the house, such as on the fridge. Such memory aids are a simple and effective means of managing the situational and to stay engaged in the treatment process (Bourgeois, 2014) whilst waiting for a specialist appointment. This will be evaluated in the same 4-week follow up appointment booked in relation to Jerry’s issues with alcohol, at which point the use of the memory aids will be reviewed and any necessary changes to their use can be identified and implemented.

 

Summary and conclusion

The above description of Jerry’s early care has provided an example of how the ADPIE process can be used to systematically approach providing  treatment for patients, even with complex and co-morbid conditions such as those in this case. ADPIE allows for nurses to use this system to methodically work through a series of symptoms and develop approaches to diagnosis, treat, and evaluate patients in both an evidence based manner, and one that is person centred (Bernard, 2017). The process is one that should be followed sequentially, and as demonstrated in the case of Jerry, this can be applied to multiple conditions at any one time. Indeed, when working with patients with long term conditions, who typically have a number of ailments or concerns, this process can be an effective means of avoiding the dangers of diagnostic overshadowing (Acharya, Schindler and Heller, 2016). The ADPIE process, in other words, allows nurses to be confident that no stone is left unturned when working with patients with complex health needs, and that they as a result receive effective, high quality care in conjunction with national clinical guidelines. Through paying close attention both to person centred and evidence based care, the ADPIE process can also be effective in engaging the patients and their families within the treatment process, which can be a significant indicator of how effective a course of treatment ultimately becomes (Eaton, Roberts and Turner, 2015). It is therefore an approach which aids both nurse and patient, and as a result, should be considered for use in all situations in which a robust treatment process is required.

 

References

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Alzheimers Association (2016). Korsakoff Syndrome. https://www.alz.org/dementia/downloads/topicsheet_korsakoff.pdf (accessed November 12, 2018).

Bernard, C., 2018. An Empirical Framework for Nursing Practice. Empirical Nursing: The Art of Evidence-Based Care, p.231.

Bourgeois, M.S., 2014. Memory and communication aids for people with dementia. Health Professions Press, Incorporated.

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Kleban, M., 2009. Motivational Interviewing in Health Care: Helping Patients Change Behavior. Psychiatric Services, 60(9), pp.1275-1276.

McDowell, I., Kristjansson, B., Hill, G.B. and Hebert, R., 1997. Community screening for dementia: The mini mental state exam (MMSE) and modified mini-mental state exam (3MS) compared. Journal of clinical epidemiology, 50(4), pp.377-383.

Maisto, S.A., Roos, C.R., O'sickey, A.J., Kirouac, M., Connors, G.J., Tonigan, J.S. and Witkiewitz, K., 2015. The indirect effect of the therapeutic alliance and alcohol abstinence self‐efficacy on alcohol use and alcohol‐related problems in Project MATCH. Alcoholism: Clinical and Experimental Research, 39(3), pp.504-513.

NICE, 2011. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. https://www.nice.org.uk/guidance/cg115/chapter/1-Guidance#identification-and-assessment (accessed November 11, 2018).

NICE, 2016. Dementia: supporting people with dementia and their carers in health and social care. https://www.nice.org.uk/guidance/cg42 (accessed November 11, 2018).

Nursing and Midwifery Council (Great Britain), 2015. The Code: Professional standards of practice and behaviour for nurses and midwives. NMC.

O'Neill, S. and Nicholson-Cole, S., 2009. “Fear Won't Do It” Promoting Positive Engagement With Climate Change Through Visual and Iconic Representations. Science Communication, 30(3), pp.355-379.

Rensen, Y.C., Kessels, R.P., Migo, E.M., Wester, A.J., Eling, P.A. and Kopelman, M.D., 2017. Personal semantic and episodic autobiographical memories in Korsakoff syndrome: A comparison of interview methods. Journal of clinical and experimental neuropsychology, 39(6), pp.534-546.

Robinson, N., Kavanagh, D., Connor, J., May, J. and Andrade, J., 2016. Assessment of motivation to control alcohol use: the motivational thought frequency and state motivation scales for alcohol control. Addictive behaviors, 59, pp.1-6.

Saunders, J.B., Aasland, O.G., Babor, T.F., De la Fuente, J.R. and Grant, M., 1993. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption‐II. Addiction, 88(6), pp.791-804.