Midwife Licensure Exam Fundamentals of Care & the Health-Care Process — The Nursing Process (ADPIE)Revision Notes

Exam Tips

• If an NLE question asks 'What is the FIRST step of the nursing process?' — the answer is always ASSESSMENT.
• When a question describes a stable patient and asks what the nurse should do first, choose the assessment-related option.
• In an EMERGENCY (e.g., no pulse, airway obstruction), the nurse implements a life-saving action FIRST — implementation precedes further assessment.
• The words 'cyclic,' 'dynamic,' 'systematic,' and 'patient-centered' describe the nursing process — memorize all four characteristics.

Key Points

• The Nursing Process is a five-phase, cyclic framework: Assessment → Diagnosis → Planning → Implementation → Evaluation (ADPIE).
• It is SYSTEMATIC (orderly, step-by-step), DYNAMIC (phases overlap and are revisited), CYCLIC (evaluation feeds back into reassessment), and PATIENT-CENTERED (individualized to each patient).
• It is GOAL-DIRECTED and OUTCOME-ORIENTED — every step aims to achieve measurable patient outcomes.
• It is UNIVERSALLY APPLICABLE across all clinical settings, age groups, and healthcare levels (primary, secondary, tertiary) in the Philippines.
• It is grounded in CRITICAL THINKING and EVIDENCE-BASED PRACTICE.
• Under RA 9173, the nursing process defines the scope of professional nursing practice in the Philippines — nurses are legally accountable for each phase.
• The process is not linear but cyclic — if goals are not met during Evaluation, the nurse returns to Assessment to gather new data and revise the plan.

Definitions

Section Title

Overview and Characteristics of the Nursing Process

Common Mistakes

• Thinking the nursing process is a rigid, one-way linear sequence — it is cyclic and dynamic; evaluation always loops back to assessment.
• Skipping the assessment phase and jumping directly to interventions — even in urgent situations, a rapid assessment (ABCs) is performed first.
• Confusing the nursing process with medical protocols — nursing process is patient-response focused, not disease-management focused.
• Forgetting that all five phases require documentation — incomplete charting is a legal and professional liability under RA 9173.

Exam Tips

• Memorize the abdominal exam exception: IAPP (Inspect, Auscultate, Percuss, Palpate) — it will appear in NLE as a single-question item.
• Classify each data item: 'Patient reports chest pain' = SUBJECTIVE; 'Respiratory rate 28/min' = OBJECTIVE.
• The patient is always the PRIMARY source — family records and labs are secondary.
• NLE will give you a scenario and ask which action is done FIRST — if assessing a stable patient, the first action is always data collection (assessment).
• Validate before you diagnose — if a question asks what you do after collecting data, the answer is VALIDATE then DOCUMENT.

Key Points

• Assessment is the FIRST and MOST CRITICAL phase — it is the foundation upon which all other phases depend.
• It involves the deliberate, systematic collection, validation, organization, and documentation of patient data.
• Two types of data: SUBJECTIVE DATA (symptoms/covert) — what the patient reports (e.g., 'I feel dizzy,' pain, nausea); only the patient can provide this. OBJECTIVE DATA (signs/overt) — observable and measurable findings (e.g., BP 150/90 mmHg, temperature 38.5°C, cyanosis).
• PRIMARY SOURCE of data: the PATIENT (always preferred). SECONDARY SOURCES: family members, medical records, laboratory results, other health professionals.
• Three main methods: INTERVIEW (health history), PHYSICAL EXAMINATION, and OBSERVATION.
• Physical exam sequence: Inspect → Palpate → Percuss → Auscultate — EXCEPT for the ABDOMEN, where the sequence is Inspect → Auscultate → Percuss → Palpate (auscultation must come before palpation/percussion to avoid altering bowel sounds).
• Steps of assessment in order: COLLECT data → VALIDATE data → ORGANIZE/CLUSTER data → DOCUMENT data.
• VALIDATION means confirming that data is accurate and complete — it distinguishes raw cues from interpreted inferences.
• CUE: a piece of data perceived directly by the nurse (e.g., 'patient is grimacing,' 'BP 90/60 mmHg'). INFERENCE: the nurse's interpretation of cues (e.g., 'the patient appears to be in pain').
• Types of assessment: INITIAL/COMPREHENSIVE (complete database at admission — establishes the baseline), FOCUSED/PROBLEM-ORIENTED (targets a specific system or problem), EMERGENCY (rapid, life-threat ABCs), ONGOING/TIME-LAPSED (reassessment over time to track changes).

Definitions

Section Title

Phase 1: Assessment — Data Collection and Validation

Common Mistakes

• Mixing up subjective and objective data — remember: SUBJECTIVE = the patient SAYS it; OBJECTIVE = the nurse SEES/MEASURES it.
• Using the wrong abdominal assessment sequence — always Inspect → AUSCULTATE → Percuss → Palpate for the abdomen.
• Treating an inference as a fact without validation — always validate cues before drawing conclusions.
• Listing the secondary source before the primary source — the patient is ALWAYS the primary and preferred source of data.
• Confusing focused assessment with ongoing assessment — focused targets a specific problem; ongoing tracks changes over time.

Exam Tips

• In NLE, always look for the option that describes a HUMAN RESPONSE (how the patient is affected), not the disease itself.
• If the question says 'the patient has not yet developed the problem but is at risk' — choose a RISK diagnosis with PE format only.
• The nursing diagnosis must be CHANGEABLE — if the answer option is a disease name (e.g., 'Hypertension'), it is a medical diagnosis and NOT a nursing diagnosis.
• Memorize key NANDA-I nursing diagnoses: Ineffective airway clearance, Impaired gas exchange, Risk for falls, Acute pain, Deficient fluid volume, Impaired skin integrity.
• Collaborative problems start with 'Potential complication:' — they are NOT independent nursing diagnoses.

Key Points

• A nursing diagnosis is a CLINICAL JUDGMENT about the patient's RESPONSE to actual or potential health problems — it is an INDEPENDENT nursing function.
• It differs from a medical diagnosis: MEDICAL DIAGNOSIS = identifies a disease/pathology, remains CONSTANT (e.g., Pneumonia). NURSING DIAGNOSIS = addresses human responses, can CHANGE as the patient's condition changes (e.g., Ineffective airway clearance).
• NANDA-I classifications: ACTUAL (problem-focused) — present at time of assessment; RISK — vulnerability to a problem not yet present; HEALTH-PROMOTION/WELLNESS — motivation to improve well-being; SYNDROME — cluster of diagnoses occurring together.
• Format for ACTUAL NURSING DIAGNOSIS (PES/Three-part): Problem + Etiology (related to...) + Signs/Symptoms (as evidenced by...). Example: 'Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by SpO2 of 88% and dyspnea.'
• Format for RISK NURSING DIAGNOSIS (PE/Two-part): Problem + Risk Factors (as evidenced by... is OMITTED because there are NO signs/symptoms yet). Example: 'Risk for falls as evidenced by history of falls and altered gait.' NOTE: Risk factors are listed, not signs/symptoms.
• The ETIOLOGY (related to...) must be something the NURSE can address — NEVER write a medical diagnosis as the etiology.
• COLLABORATIVE PROBLEMS: potential complications monitored and managed jointly by nursing and medicine (e.g., 'Potential complication: hemorrhage') — distinct from independent nursing diagnoses.
• A well-written nursing diagnosis is SPECIFIC, ACCURATE, based on VALIDATED data, and derived from assessment findings.

Definitions

Section Title

Phase 2: Nursing Diagnosis — Clinical Judgment and Problem Identification

Common Mistakes

• Writing the medical diagnosis instead of the human response (e.g., writing 'Pneumonia' instead of 'Ineffective airway clearance').
• Including 'as evidenced by' (signs/symptoms) in a RISK nursing diagnosis — risk diagnoses have NO signs/symptoms; only risk factors.
• Writing a nursing intervention as the problem (e.g., 'Needs suctioning' — this is an intervention, not a diagnosis).
• Using a medical diagnosis as the etiology (e.g., '...related to pneumonia' — instead write '...related to excessive secretions').
• Reversing the problem and etiology in the PES format — the PROBLEM comes first, then the etiology.
• Making a judgmental or legally inadvisable statement in the diagnosis (e.g., implying patient negligence).

Exam Tips

• When asked to select the PRIORITY nursing diagnosis, always apply Maslow: physiologic first, then safety, then psychosocial.
• Among physiologic problems, apply ABC: airway first, then breathing, then circulation.
• Identify incorrectly written goals: if the goal lacks a time frame or uses an unmeasurable verb, it is WRONG.
• The patient must be INVOLVED in goal-setting — mutual goal-setting is a key principle of patient-centered care.
• Actual before risk; acute before chronic — these priority rules work alongside Maslow.

Key Points

• Planning involves setting PRIORITIES, writing GOALS/OUTCOMES, and selecting NURSING INTERVENTIONS — the result is a written CARE PLAN.
• PRIORITY SETTING uses Maslow's Hierarchy: 1. Physiologic needs (airway, breathing, circulation, oxygen, nutrition, fluids, elimination, rest) — ALWAYS FIRST. 2. Safety and security. 3. Love and belonging. 4. Self-esteem. 5. Self-actualization.
• ABC RULE: AIRWAY is always first, then BREATHING, then CIRCULATION — applies within physiologic priority level.
• Priority logic: ACTUAL (present) problems before POTENTIAL (risk) problems; ACUTE problems before CHRONIC problems; LIFE-THREATENING before non-life-threatening.
• Types of planning: INITIAL (after first assessment), ONGOING (continuously updated), DISCHARGE (begins on admission to ensure continuity of care — even in Philippine barangay-to-hospital referrals).
• Goals must be SMART: SPECIFIC, MEASURABLE, ATTAINABLE, REALISTIC, TIME-BOUND.
• Goals are PATIENT-CENTERED — written from the patient's perspective, using measurable action verbs. Example: 'The patient will ambulate 3 meters unassisted by day 2 post-op.'
• SHORT-TERM GOALS: achieved within hours to days. LONG-TERM GOALS: achieved over weeks to months.
• Use MEASURABLE VERBS: verbalize, demonstrate, walk, list, state, perform. AVOID vague verbs: understand, know, feel, appreciate — these cannot be measured.
• Nursing interventions (nursing orders) must specify WHAT, WHEN, HOW OFTEN, and BY WHOM — they must be safe, evidence-based, and within the nurse's competence.

Definitions

Section Title

Phase 3: Planning — Goals, Outcomes, and Interventions

Common Mistakes

• Writing goals that are NURSE-centered instead of PATIENT-centered (e.g., 'The nurse will teach the patient...' is wrong — correct: 'The patient will demonstrate...').
• Using unmeasurable verbs like 'understand,' 'know,' or 'appreciate' in goal statements.
• Omitting a TIME FRAME from the goal — without a deadline, the goal cannot be evaluated.
• Prioritizing a RISK problem over an ACTUAL problem when the actual problem is physiologic.
• Forgetting that discharge planning begins on ADMISSION — it is not done only at the time of discharge.

Exam Tips

• If the NLE asks when to document: AFTER the intervention — never before.
• If asked which tasks can be delegated to a nursing aide: only STABLE, ROUTINE, non-assessment tasks (e.g., assisting with bathing, recording intake/output for a stable patient).
• Assessment, evaluation, nursing diagnosis, and teaching are NEVER delegated to UAP.
• The nurse is ALWAYS accountable for delegated tasks — delegation transfers responsibility for performance, not accountability.
• Reassess BEFORE implementing — this is the first step of implementation, not a return to the assessment phase.

Key Points

• Implementation is the ACTION phase — carrying out the nursing interventions identified in the care plan.
• Three types of nursing interventions: INDEPENDENT (nurse-initiated, within scope of practice — e.g., positioning, health teaching, encouraging oral fluids); DEPENDENT (physician-initiated — e.g., administering prescribed medications); COLLABORATIVE/INTERDEPENDENT (done with other health team members — e.g., wound care with the physician).
• Before implementing: REASSESS the patient (conditions may have changed since planning).
• Key nursing actions during implementation: Reassess → Set priorities → Perform interventions safely → Delegate appropriately → Document.
• DOCUMENTATION: Always document AFTER (never BEFORE) the intervention is carried out. Pre-charting is a professional and legal violation.
• DELEGATION: Nurses may delegate appropriate tasks using the FIVE RIGHTS OF DELEGATION: Right Task, Right Circumstance, Right Person, Right Direction/Communication, Right Supervision/Evaluation.
• Tasks that CANNOT be delegated to unlicensed assistive personnel (UAP): Assessment, Nursing Diagnosis, Planning, Evaluation, Teaching, and care of UNSTABLE patients — these require professional nursing judgment.
• Nurses RETAIN ACCOUNTABILITY for all delegated tasks — delegation does not remove the nurse's responsibility for the outcome.
• Under RA 9173, implementing nursing interventions is a core function of the professional nurse — only licensed nurses may perform nursing acts independently.

Definitions

Section Title

Phase 4: Implementation — Executing the Plan

Common Mistakes

• Charting (documenting) BEFORE performing the intervention — this is legally and ethically incorrect and constitutes falsification of records.
• Delegating assessment, evaluation, teaching, or care of unstable patients to nursing aides or UAP — these tasks require professional nursing judgment.
• Failing to reassess the patient before implementing — patient conditions change, and planned interventions may no longer be appropriate.
• Confusing independent with dependent interventions — administering medications ALWAYS requires a physician order (dependent).

Exam Tips

• NLE question pattern: 'The patient did not achieve the expected outcome. What should the nurse do?' — Answer: REASSESS and REVISE the care plan.
• Evaluation always compares actual response vs. expected outcome — match these two elements.
• Memorize the three outcomes: MET, PARTIALLY MET, NOT MET — and what each triggers.
• If a goal is met, the nurse may discontinue that specific nursing diagnosis from the care plan.
• Evaluation is never the last step in a cyclic process — it always leads back to assessment.

Key Points

• Evaluation is the FINAL phase — the nurse compares the patient's ACTUAL RESPONSE against the stated OUTCOME CRITERIA to determine if goals were met.
• Three possible outcomes: GOAL MET (patient achieved the expected outcome), GOAL PARTIALLY MET (patient showed progress but did not fully achieve the outcome), GOAL NOT MET (patient did not achieve the expected outcome).
• If the goal is NOT MET or PARTIALLY MET: the nurse REASSESSES, identifies the reason for failure, REVISES the care plan, and continues the cycle — this is what makes the nursing process CYCLIC.
• Evaluation also assesses the QUALITY and APPROPRIATENESS of nursing interventions — were the right actions chosen?
• Evaluation is an ONGOING process — it does not occur only at the end of care but continuously throughout.
• Evaluation feeds BACK into reassessment — new data gathered during evaluation triggers a new cycle of ADPIE.
• Evaluation must be DOCUMENTED — including whether goals were met, the patient's actual response, and any revisions to the plan.
• Evaluation is an INDEPENDENT nursing function — the nurse evaluates outcomes based on professional judgment.

Definitions

Section Title

Phase 5: Evaluation — Measuring Goal Achievement

Common Mistakes

• Thinking evaluation occurs ONLY at discharge — evaluation is ongoing and continuous throughout the episode of care.
• Stopping care after evaluation without reassessing when goals are not met — if a goal is not met, you must reassess and revise the plan.
• Evaluating outcomes against vague or unmeasurable goals — this is why SMART goals with measurable verbs and time frames are essential.
• Forgetting to document the evaluation findings and any plan revisions.

Exam Tips

• Read the stem carefully: Is the patient STABLE or in an EMERGENCY? This determines whether you assess first or intervene first.
• Match the answer choice to the correct PHASE: if the question asks what to do FIRST and the patient is stable, the first-phase answer (assessment) is usually correct.
• Look for MEASURABLE verbs in goal/outcome answer choices — the option with 'the patient will DEMONSTRATE...' and a time frame is usually correct.
• Eliminate options that: use medical diagnoses as nursing diagnoses, include signs/symptoms in risk diagnoses, or write nurse-centered goals.
• Know the mnemonic ADPIE backwards and forwards — many NLE questions test whether you can sequence the phases correctly.

Key Points

• GOLDEN RULE: When a patient is STABLE, always ASSESS FIRST before acting. When in an EMERGENCY (airway obstruction, no pulse, active hemorrhage), INTERVENE IMMEDIATELY — implementation precedes further assessment.
• Identify the PHASE of the nursing process from the action described: Collecting vital signs = Assessment; Writing 'Ineffective airway clearance related to...' = Diagnosis; Writing a care plan with goals = Planning; Administering oxygen = Implementation; Checking if SpO2 improved = Evaluation.
• PRIORITY FRAMEWORKS combined: Maslow (physiologic first) + ABC (airway, breathing, circulation) + Actual before Risk + Acute before Chronic.
• When two options are both physiologic, use ABC to decide: airway problem beats a circulation problem.
• When two options are both actual, use Maslow sub-levels — the more basic the need, the higher the priority.
• ABDOMINAL EXAM SEQUENCE (highest-yield single fact): Inspect → Auscultate → Percuss → Palpate (IAPP).
• PES vs. PE: ACTUAL = PES (three parts with signs/symptoms); RISK = PE (two parts, NO signs/symptoms).
• DELEGATION quick rule: stable + routine + no judgment needed = can delegate; assessment + evaluation + teaching + unstable = CANNOT delegate.
• DOCUMENTATION: Document AFTER performing the intervention — pre-charting is professional misconduct.
• Under RA 9173, nursing practice in the Philippines encompasses the full ADPIE cycle — nurses are accountable for all five phases.

Section Title

NLE Test-Taking Strategy and Priority Frameworks

Common Mistakes

• Choosing 'implement' when the correct answer is 'assess' for a stable patient — always assess first unless there is an emergency.
• Choosing 'assess' when the correct answer is 'implement' for an emergency — in life-threatening situations (no airway, no pulse), act immediately.
• Selecting a psychosocial nursing diagnosis as the PRIORITY when a physiologic problem is also present.
• Choosing a risk diagnosis as the priority over an actual diagnosis involving physiologic needs.