The nursing process (ADPIE)

The nursing process is a systematic, client-centered method of planning and delivering care. The NLE loves it because almost every "what should the nurse do first" item is really asking you to identify which step you are in. Remember ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation. The steps are sequential but overlapping and cyclic; evaluation feeds back into assessment.

Assessment: collect and verify data

Assessment is the systematic collection, verification, organization, and documentation of client data. Two classifications matter for the boards.

By type of data:

• Subjective data (symptoms): what the client says. "I feel dizzy." Pain, nausea, anxiety, and itching are always subjective.
• Objective data (signs): what the nurse observes or measures. BP 90/60, wound drainage, a grimace, laboratory results.

By source:

• Primary source: the client. The client is always the primary source, even when confused, as long as data comes directly from him or her.
• Secondary sources: family, chart, other health workers, laboratory reports, literature.

Validate data when subjective and objective findings conflict, then organize (for example by Gordon's functional health patterns) and document. Assessment ends with a data base, not a conclusion.

Diagnosis: analyze and label

The nursing diagnosis is a clinical judgment about a human response to an actual or potential health problem that the nurse is licensed to treat. It differs from a medical diagnosis, which names the disease and stays constant; a nursing diagnosis changes as the response changes.

PES format:

• P (Problem): the NANDA label, e.g., Ineffective airway clearance.
• E (Etiology): "related to" a cause the nurse can address. Never write "related to" a medical diagnosis; use its effects instead.
• S (Signs and symptoms): "as evidenced by" the defining characteristics.

Diagnosis type	Structure	Example
Actual	Problem + etiology + signs/symptoms	Impaired skin integrity related to immobility as evidenced by a stage 2 sacral ulcer
Risk	Risk label + risk factors (no signs yet)	Risk for falls related to gait instability
Health promotion	Readiness label, client desire to improve	Readiness for enhanced nutrition

A risk diagnosis has no "as evidenced by" clause because the problem has not occurred.

Planning: prioritize, set goals, select interventions

Planning involves setting priorities (use Maslow and ABC), writing goals and expected outcomes, and choosing interventions. Goals must be client-centered, starting with "The client will..."

SMART goals are Specific, Measurable, Attainable, Realistic, and Time-bound. "The client will ambulate 20 meters with a walker by discharge" is SMART; "The client will improve mobility" is not measurable. Short-term goals are achievable within hours to about a week; long-term goals span weeks to months. The planning step ends with a written, individualized care plan.

Implementation: act and document

Implementation is carrying out (or delegating) the planned interventions while continuing to assess. Types of interventions:

• Independent: nurse-initiated, no order needed (turning, teaching, positioning).
• Dependent: require a physician order (medications, most treatments).
• Collaborative or interdependent: carried out with other team members (dietitian, physical therapist).

Reassess before acting, perform the intervention safely, then document what was done and the client response. An intervention not documented is legally considered not done.

Evaluation: compare outcomes to goals

Evaluation is a planned, ongoing judgment of whether goals were met, partially met, or not met, always measured against the stated outcome criteria, not against the interventions. If a goal is unmet, the nurse reviews every step: was the assessment complete, was the diagnosis accurate, was the goal realistic, were interventions carried out? Modify the care plan rather than discarding it.

Key points

• Order is ADPIE; when a question asks what to do "first," pick the assessment-type option if the data are incomplete.
• Subjective = stated by client; objective = observed or measured. Pain is subjective even when the client grimaces.
• Client is the primary data source; chart and family are secondary.
• PES: problem, etiology ("related to"), signs ("as evidenced by"); risk diagnoses omit the S.
• Never link the etiology to a medical diagnosis; link it to the client response the nurse can treat.
• Goals are client-centered, SMART, and set during planning; evaluation compares client outcomes to those goals.
• Independent interventions need no order; dependent ones do.

Exam-day strategy

• Identify the step being tested before reading the choices; eliminate options that belong to a different step.
• "Assess before you act" wins unless the stem already gives complete assessment data or describes an emergency needing immediate action.
• Watch for goal statements that describe nurse actions instead of client outcomes; those are wrong.