The Nursing Process (ADPIE) - Cheat Sheet
Your last-minute revision companion for mastering ADPIE, the five-phase systematic framework that underpins every clinical decision on the NLE. This sheet condenses the priorities, sequences, and test strategies you need in the final 30 minutes before exam day.
Phase 1: ASSESSMENT — Data Collection & Validation
Important facts
- Assessment is the FIRST step in ADPIE — errors here cascade through the entire process.
- Collect → Validate → Organize/Cluster → Document is the correct assessment sequence.
- ABDOMINAL EXAM sequence is UNIQUE: Inspect → Auscultate → Percuss → Palpate (never palpate first; it disturbs bowel sounds).
- ALL OTHER exams: Inspection → Palpation → Percussion → Auscultation.
- Initial/comprehensive assessment = complete database on admission; establishes baseline.
- Focused assessment = targets one problem or body system (e.g., respiratory, wound).
- Emergency assessment = rapid, ABCs-focused during crisis; may skip full exam.
- Ongoing assessment = continuous reassessment to track changes and evaluate care.
- Patient is ALWAYS the primary source; secondary sources support, never replace, patient report.
- Data must be validated BEFORE diagnosis is made — avoid jumping to conclusions based on assumptions.
- Clustering/grouping data helps identify patterns and supports diagnosis formulation.
Key definitions
Assessment
Example
Nurse collects vital signs, asks about pain, reviews medical history on admission.
Deliberate, systematic collection of subjective and objective data about the patient's health status; foundation of the entire nursing process.
Subjective Data (Symptoms/Covert)
Example
Patient says: 'I feel dizzy,' 'My stomach hurts,' 'I haven't slept in two days.'
Information only the patient can provide; what the patient states, feels, or reports.
Objective Data (Signs/Overt)
Example
BP 150/90, temperature 38.5°C, SpO₂ 88%, grimacing, cyanosis.
Observable, measurable, verifiable data obtained through physical exam or diagnostic tests.
Primary Source
Example
Direct interview and physical examination of the patient.
The patient; the most reliable and preferred source of health information.
Secondary Source
Example
Spouse reports patient forgets to take medications; chart shows prior HTN diagnosis.
Family, friends, medical records, other healthcare professionals, lab/diagnostic results.
Cue
Example
Grimacing, BP 90/60, patient states 'I'm in pain.'
Direct observation of data (objective or subjective) the nurse perceives; a fact without interpretation.
Inference
Example
Seeing grimacing + hearing 'I'm in pain' → inference: 'Patient is experiencing pain.'
The nurse's interpretation or judgment about the meaning of a cue; a conclusion drawn from data.
Validation
Example
Ask patient 'On a scale of 0-10, how severe is your pain?' to validate the pain inference.
Confirming accuracy of data; distinguishing cues from inferences before documenting.
Diagrams to know
- Assessment data collection funnel (primary → secondary sources).
- Cue vs Inference decision tree (data → interpretation flow).
- Assessment phases flowchart (Collect → Validate → Organize → Document).
Phase 2: NURSING DIAGNOSIS — Clinical Judgment & Problem Identification
Important facts
- ACTUAL DIAGNOSIS = 3-part (PES): Problem + Etiology ('related to') + Signs/Symptoms ('as evidenced by').
- RISK DIAGNOSIS = 2-part (PE): Problem + Risk Factors (NO 'as evidenced by' because signs/symptoms don't exist yet).
- NEVER write a medical diagnosis as the etiology — nursing diagnoses address RESPONSES, not diseases.
- NEVER state a need or nursing intervention as the diagnosis — this is a common error (e.g., 'needs suctioning' is wrong).
- NEVER reverse P and E — the problem comes first, cause comes second.
- Etiology must be something NURSING can manage — 'related to diabetes' fails; 'related to hyperglycemia and decreased mobility' works.
- Signs/symptoms MUST match the problem-etiology pair — consistency validates the diagnosis.
- Each diagnosis is derived FROM ASSESSMENT DATA, never assumed or predetermined.
- Nursing diagnosis is INDEPENDENT function (within RA 9173 nursing scope); does not require physician approval.
- Collaborative problems differ from nursing diagnoses — they are potential complications, not human responses.
- A patient may have multiple nursing diagnoses; prioritize using Maslow + ABC.
Key definitions
Nursing Diagnosis
Example
Ineffective airway clearance related to excess mucus production as evidenced by adventitious breath sounds.
Clinical judgment about the patient's RESPONSE (not disease) to actual or potential health problems; independent nursing function; may change as condition changes.
Medical Diagnosis
Example
Pneumonia, diabetes mellitus, myocardial infarction.
Identification of a disease or pathological condition; physician-made; remains constant throughout the illness.
Actual (Problem-Focused) Diagnosis
Example
Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by SpO₂ 88%.
A problem present NOW at the time of assessment; supported by signs and symptoms.
Risk Diagnosis
Example
Risk for falls related to history of falls and altered gait.
Vulnerability to a problem that HAS NOT YET OCCURRED; no signs/symptoms present; supported by risk factors only.
Health-Promotion/Wellness Diagnosis
Example
Readiness for enhanced nutrition management related to desire to improve diet.
Motivation to increase well-being in an area; patient demonstrates motivation for better health.
Syndrome Diagnosis
Example
Post-trauma response; relocation stress syndrome.
A cluster of nursing diagnoses occurring together in response to a single event or situation.
Problem (P) — PES Format
Example
Ineffective airway clearance; Impaired skin integrity.
The nursing diagnosis label; the human response or problem statement.
Etiology (E) — 'Related To'
Example
Related to decreased level of consciousness; related to immobility.
The cause or contributing factor of the problem; something the nurse CAN address (never a medical diagnosis).
Signs/Symptoms (S) — 'As Evidenced By'
Example
As evidenced by wheezing, dyspnea, and SpO₂ 88%.
Cues that support the diagnosis; the data that validate the problem and etiology (ONLY in actual diagnoses).
Risk Factors (Risk Diagnoses Only)
Example
Related to age over 75 years and polypharmacy.
Conditions or characteristics that increase vulnerability to a problem; replaces 'as evidenced by'.
Collaborative Problems
Example
Potential complication: hemorrhage; PC: acute coronary syndrome.
Potential complications requiring BOTH nursing AND physician intervention; nurse monitors and manages with MD.
Diagrams to know
- PES (Problem-Etiology-Signs/Symptoms) format structure for actual diagnoses.
- PE (Problem-Etiology) format for risk diagnoses — why 'as evidenced by' is omitted.
- NANDA-I diagnosis classification tree (actual, risk, health-promotion, syndrome).
- Diagnostic error checklist (reversed P-E, medical diagnosis as etiology, need instead of problem).
Phase 3: PLANNING — Priorities, Goals, Outcomes & Interventions
Important facts
- MASLOW'S HIERARCHY guides priority: Physiologic → Safety → Love/Belonging → Esteem → Self-Actualization.
- ABC FIRST: Airway ALWAYS takes priority, then Breathing, then Circulation.
- ACTUAL BEFORE RISK: Address present problems before potential ones.
- ACUTE BEFORE CHRONIC: Acute problems take priority over stable, chronic conditions.
- LIFE-THREATENING BEFORE NON-LIFE-THREATENING: Always.
- Goals are PATIENT-CENTERED, not nurse-centered — use measurable action verbs.
- Avoid vague verbs (understand, know, feel) — use observable verbs (verbalize, demonstrate, walk, list, state).
- Each outcome must have SUBJECT (patient), ACTION VERB, CONDITIONS/CRITERIA, and TIME FRAME.
- Initial planning = comprehensive after first assessment; ongoing = updated daily; discharge = begun on admission.
- Interventions should specify WHAT, WHEN, HOW OFTEN, and BY WHOM.
- Consider patient preferences, resources, and cultural context when selecting interventions.
- ALL interventions should be evidence-based, safe, and within nurse's competence.
- Delegate using FIVE RIGHTS: right task, right circumstance, right person, right direction, right supervision.
Key definitions
Planning
Example
Setting goal 'Patient will ambulate 3 meters without assistance by day 2' and planning mobility interventions.
Establishment of priorities, goals/outcomes, and nursing interventions; results in the patient care plan.
Priority Setting
Example
Address airway before pain; address actual problem before risk diagnosis.
Ranking problems and interventions by urgency using frameworks (Maslow, ABC, actual vs risk, acute vs chronic).
Goal (Long-Term Goal)
Example
Patient will demonstrate effective stress-management techniques by discharge.
Broad, general outcome expected over WEEKS to MONTHS; often relates to discharge or problem resolution.
Short-Term Goal/Outcome
Example
Patient will verbalize one stress-management technique by end of shift.
Specific, measurable result expected within HOURS to DAYS; intermediate steps toward long-term goal.
SMART Outcome
Example
Patient will walk 10 meters with walker by 0800 tomorrow (not 'improve mobility').
Specific (clear), Measurable (quantifiable), Attainable (achievable), Realistic (feasible), Time-bound (deadline).
Nursing Intervention
Example
Assist patient to ambulate 10 meters tid; provide pain medication 30 min before activity.
A specific action or nursing order designed to help the patient achieve the outcome; may be independent, dependent, or collaborative.
Independent Intervention
Example
Positioning, health teaching, encouraging fluids, assessing pain, wound care.
Nursing action within the nurse's scope and authority; does NOT require physician order.
Dependent Intervention
Example
Administering medications, inserting catheter, implementing diet order.
Action carried out on physician order; nurse executes but physician is responsible for the order.
Collaborative/Interdependent Intervention
Example
Physical therapy for mobility; dietary consultation for nutrition; respiratory therapy for airway.
Action done WITH other health professionals (PT, OT, nutrition, respiratory therapy); shared responsibility.
Care Plan
Example
Standardized or individualized care plan in the patient's medical record or EHR.
Written documentation of the patient's problems, goals, interventions, and evaluation; guides all nursing care.
Diagrams to know
- Maslow's Hierarchy of Needs pyramid with physiologic at base, self-actualization at top.
- ABC priority ordering (Airway → Breathing → Circulation).
- Outcome writing formula: Subject + Measurable Verb + Condition/Criteria + Time Frame.
- Intervention selection flowchart (is it safe? evidence-based? within scope?).
Phase 4: IMPLEMENTATION — Executing the Care Plan
Important facts
- ALWAYS reassess BEFORE implementing — conditions change; patient status may differ from care plan.
- ALWAYS document AFTER, never BEFORE, performing the intervention.
- Direct action: Independent and dependent interventions are performed by the nurse.
- Indirect action: Consulting, referrals, coordinating interdisciplinary care.
- Teaching and patient education are independent nursing functions during implementation.
- Safety is paramount — use proper technique, prevent injury, follow protocols.
- Explain the intervention to the patient; obtain consent when needed (respect autonomy).
- Monitor patient response during and after intervention; document any adverse reactions.
- CANNOT delegate: Assessment, evaluation, nursing judgment, teaching, care of unstable patient.
- CAN delegate: Hygiene, ambulation, vital signs, simple tasks to competent UAP.
- Nurse retains ACCOUNTABILITY for delegated task — must supervise and evaluate outcome.
- Use evidence-based practice; follow facility protocols and standards of care.
- In emergency (no airway, no pulse): SKIP assessment, intervene immediately (CPR, airway).
- In stable situation: Always ASSESS FIRST before deciding on intervention.
Key definitions
Implementation
Example
Administering medication, assisting with ambulation, providing wound care, teaching patient.
Execution of the nursing care plan; carrying out planned interventions with appropriate technique, safety, and documentation.
Reassessment (Before Intervention)
Example
Check BP before helping patient stand; assess pain before giving analgesic.
Quick check of patient's current status BEFORE implementing an action; conditions may have changed.
Prioritization During Implementation
Example
Address critical issues first; cluster interventions to minimize patient disruption.
Sequencing interventions based on urgency, patient needs, and efficiency during shift.
Documentation
Example
Charted after giving meds, after wound care, after teaching — never before.
Recording of the intervention AFTER completion, including what was done, patient response, and outcome.
Delegation
Example
Delegate vital signs, hygiene, ambulation to UAP; CANNOT delegate assessment, evaluation, teaching to UAP.
Assignment of a task to an unlicensed assistive personnel (UAP) or other team member within their scope.
Five Rights of Delegation
Example
Right task = UAP can take vitals; right person = trained UAP; right supervision = nurse checks result.
Framework ensuring safe task delegation: right task, right circumstance, right person, right direction, right supervision.
Diagrams to know
- Implementation flowchart: Reassess → Perform → Document → Evaluate Response.
- Five Rights of Delegation checklist (right task, circumstance, person, direction, supervision).
- What CAN vs CANNOT be delegated to UAP (delegation boundaries).
Phase 5: EVALUATION — Determining Goal Achievement & Adjusting Care
Important facts
- Evaluation is CONTINUOUS — not just at end of shift or discharge.
- Compare ACTUAL PATIENT RESPONSE against the STATED OUTCOME CRITERIA — not a vague impression.
- Outcomes are MEASURABLE — use the specific criteria (numbers, distances, vitals, behaviors).
- If goal NOT MET or PARTIALLY MET → CYCLE BACK: Reassess → Revise → Re-implement.
- This CYCLIC nature makes the nursing process DYNAMIC — never a dead end.
- Document evaluation findings clearly: what happened, why, and what changes were made.
- Involve patient in evaluation when possible — get their perspective on progress.
- Multiple goals may have different timelines — evaluate each separately.
- Evaluation also examines NURSING CARE quality: Was it safe? Evidence-based? Individualized? Timely?
- If intervention ineffective → question validity, check patient adherence, consider alternatives.
- Discharge evaluation ensures patient is ready; continuity plan ensures follow-up care.
- Document disposition: Goal achieved → discontinue diagnosis; goal unmet → continue/revise plan.
Key definitions
Evaluation
Example
Goal: 'Walk 3m with walker by day 2.' Evaluation: Patient walked 3m independently on day 2 — GOAL MET.
Systematic determination of whether patient goals/outcomes were ACHIEVED; comparison of actual response against outcome criteria.
Goal Met
Example
Patient verbalized 3 stress-management techniques (goal was 2) — goal EXCEEDED.
Patient's actual response matches or exceeds the stated outcome criteria.
Goal Partially Met
Example
Patient ambulated 2 meters with walker (goal was 3) — progress made, continue intervention.
Patient made progress toward goal but did not fully achieve it; may need more time or modified approach.
Goal Not Met
Example
Patient unable to ambulate; remains bedbound — GOAL NOT MET, reassess barriers.
Patient made no progress or regressed; goal criteria not achieved; requires reassessment and plan revision.
Reassessment
Example
Patient can't ambulate — is it pain? weakness? fear? Reassess to find cause.
Collecting new data to understand why goal was not met; identifies barriers, changed conditions, or ineffective interventions.
Plan Revision
Example
If pain is barrier → add pain control; if fear is barrier → provide education and reassurance.
Modification of the care plan based on evaluation findings; change goal, intervention, or approach.
Quality of Care
Example
Were medications given on time? Was patient treated with dignity? Was goal achieved?
Evaluation of how well nursing care was delivered; appropriateness of interventions, timeliness, effectiveness.
Diagrams to know
- Evaluation outcome triangle: Met → Discontinue | Partially Met → Continue/Modify | Not Met → Reassess/Revise.
- Cycle-back flowchart: Evaluate → Compare to outcome → Met or Not Met? → Decision tree for next step.
Critical Thinking, Clinical Judgment & the Nursing Process
Important facts
- Critical thinking is the FOUNDATION of ADPIE — it drives decisions in every phase.
- Use EVIDENCE-BASED PRACTICE — current research, best practices, facility standards.
- Avoid BIAS and ASSUMPTIONS — gather data before concluding.
- Ask questions: Why? What if? Is there another explanation? What is the best evidence?
- Interpret CUES correctly — distinguish normal from abnormal, significant from insignificant.
- In NLE questions: When stable → ASSESS FIRST (critical thinking asks 'what do I need to know?').
- In emergency → INTERVENE IMMEDIATELY (critical thinking prioritizes life-threat first).
- First action vs. best action: 'First' often = assess; 'best' = most important intervention.
- Priority actions follow MASLOW + ABC logic consistently.
- Reflection after care: 'Did my intervention work? Why or why not? What would I do differently?' — this IMPROVES judgment.
- Collaboration enhances judgment — discuss with team, seek input, learn from others.
Key definitions
Critical Thinking
Example
Nurse does not automatically assume patient in pain is 'drug-seeking' — gathers data, validates, reassesses.
Disciplined, reflective reasoning that questions assumptions, analyzes evidence, and makes sound clinical decisions.
Clinical Judgment
Example
Recognizing that a patient's increased restlessness may signal pain, hypoxia, or anxiety — each requires different intervention.
Application of critical thinking to a patient situation; the ability to make the RIGHT decision in CONTEXT.
Cue Recognition
Example
Increased respiratory rate + decreased SpO₂ + dyspnea = cues for hypoxia; needs airway intervention, not calm reassurance.
Identifying significant data (patterns, abnormalities, red flags) that signal a potential problem.
Inference vs Cue (Clinical Judgment Skill)
Example
Cue: grimacing. Inference: 'patient is in pain.' Validate: Ask patient pain level — confirm inference.
Cue = what you observe; Inference = what it means. Sound judgment validates cues BEFORE drawing conclusion.
Diagrams to know
- Critical thinking cycle: Observe Cue → Analyze → Question → Validate → Infer → Act → Reflect.
- Decision tree: Is this an emergency (airway/breathing/circulation threat)? Yes = ACT. No = ASSESS.
NLE High-Yield Test Strategies & Tricky Scenarios
Important facts
- ASSESSMENT = safest first step in stable patient scenarios.
- IMPLEMENTATION (immediate life-saving measures) = correct first action in emergencies (airway obstruction, cardiac arrest, hemorrhage).
- When question says 'the nurse should do FIRST' in an emergency → choose CPR, airway maneuvers, direct pressure, NOT 'call for help' or 'stay calm'.
- When question says 'the BEST nursing diagnosis' → choose the one MOST RELATED to assessment findings and SPECIFIC to the patient.
- When comparing actual vs. risk diagnosis in priority → ALWAYS choose actual.
- When comparing two actual diagnoses → use MASLOW (physiologic > safety > other); use ABC (airway > breathing > circulation).
- When setting outcomes → avoid vague verbs (understand, know); use measurable verbs (walk, verbalize, list, state, demonstrate).
- When writing nursing diagnosis → if etiology is medical diagnosis (e.g., 'related to pneumonia') → WRONG; rewrite as 'related to impaired gas exchange.'
- When delegating → CANNOT delegate assessment, teaching, evaluation, or care of unstable patient.
- When evaluating → if goal NOT MET → reassess, revise, continue cycle (NOT 'discontinue').
- NANDA-I actual diagnosis format: Problem (P) + Etiology (E) + Signs/Symptoms (S) = PES.
- NANDA-I risk diagnosis format: Problem (P) + Risk Factors = PE (no 'as evidenced by').
- Abdominal exam ONLY sequence = Inspect → Auscultate → Percuss → Palpate; all others = Inspection → Palpation → Percussion → Auscultation.
- Document AFTER intervention, not before; reassess BEFORE implementing.
- Cyclic process: Evaluation → Not Met? → Reassess → Revise Plan → Re-implement → Re-evaluate.
Key definitions
First Action vs. Best Action
Example
Patient short of breath: 'First action'? Assess — listen to breath sounds, check SpO₂. Then intervene (oxygen, position, notify MD).
First = immediate, urgent action (assess or intervene). Best = most effective for outcome. In stable patients, 'first' usually = assess.
Actual vs. Potential Problem Priority
Example
Patient with ACTUAL pain (present) + RISK for skin breakdown (not yet present) → treat pain first.
ACTUAL (happening NOW) takes priority over RISK (might happen). An actual problem must be addressed before preventing a risk.
Acute vs. Chronic Priority
Example
Patient with CHRONIC hypertension (stable) + ACUTE MI (new) → treat MI first.
ACUTE (sudden, urgent) takes priority over CHRONIC (long-standing, stable). Exception: Chronic exacerbation = acute.
Diagrams to know
- First Action Decision Tree: Emergency (airway threat)? → Intervene. Stable? → Assess.
- Priority Decision Matrix: Maslow level + ABC + Actual/Risk + Acute/Chronic.
Must remember
- ADPIE is CYCLIC, not linear — Evaluation feeds back into Assessment for continuous improvement. If goal not met, REASSESS → REVISE → IMPLEMENT again.
- ASSESSMENT ALWAYS FIRST in stable patients — Never skip data collection before forming a diagnosis or choosing an intervention. In emergencies (no airway/pulse), INTERVENE immediately before full assessment.
- The PATIENT is the PRIMARY SOURCE — All subjective data comes from patient; secondary sources (family, records, diagnostics) SUPPORT but never REPLACE patient report.
- ABDOMINAL EXAM SEQUENCE IS UNIQUE — Inspect → Auscultate → Percuss → Palpate. All other exams: Inspect → Palpate → Percuss → Auscultate. (This is a guaranteed NLE question.)
- NURSING DIAGNOSIS addresses RESPONSES, not diseases — Never write a medical diagnosis as etiology; Never state a need/intervention as the diagnosis. Write actual human response problems: 'Ineffective airway clearance,' not 'pneumonia' or 'needs suctioning.'
- PES = Problem + Etiology + Signs/Symptoms (ACTUAL diagnosis only); PE = Problem + Risk Factors (RISK diagnosis, NO signs/symptoms). This 2-part vs 3-part distinction is HIGH-YIELD on NLE.
- MASLOW + ABC = Priority Setting Framework — Physiologic (ABCs) > Safety > Love/Belonging > Esteem > Self-Actualization. AIRWAY ALWAYS FIRST. Use this for every priority question.
- SMART OUTCOMES must be Specific, Measurable, Attainable, Realistic, Time-bound — Use observable verbs (walk, verbalize, list, demonstrate), NOT vague verbs (understand, know, feel). Each outcome: Subject + Verb + Condition/Criteria + Timeframe.
- DOCUMENT AFTER, NEVER BEFORE — Reassess immediately BEFORE implementing. This timing sequence is critical for safe, accountable practice and is heavily tested on NLE.
- DELEGATION: Can delegate task (UAP takes vitals), CANNOT delegate assessment, evaluation, teaching, or unstable-patient decisions — Nurse ALWAYS retains accountability. Use Five Rights to guide safe delegation.
Last minute tips
- When reading NLE questions: STABLE patient + 'what should nurse do FIRST?' = ASSESS. EMERGENCY patient (no airway/pulse/BP) = INTERVENE immediately. Learn this distinction — it's the #1 test strategy.
- ACTUAL diagnosis always beats RISK diagnosis in priority. If question offers both, choose ACTUAL without second-guessing. Same logic: ACUTE beats CHRONIC, PHYSIOLOGIC beats PSYCHOSOCIAL.
- Write EVERY diagnosis in PES or PE format from ASSESSMENT data — never assume. If you can't link it to collected cues, the diagnosis is unsupported. On exam, expect questions asking 'which diagnosis is BEST supported by the data?' — match cues to signs/symptoms in diagnosis.
- When you see 'related to' in a diagnosis answer, CHECK THE ETIOLOGY — If it's a medical diagnosis (pneumonia, cancer, diabetes), that answer is WRONG. Etiologies must be nursing-addressable (decreased mobility, altered gas exchange, pain, fear).
- OUTCOMES must be patient-centered & measurable — Avoid 'improve,' 'increase,' 'enhance' without numbers/specifics. 'Patient will walk 10m with walker by EOD' (measurable) beats 'Patient will improve mobility' (vague). Every outcome on the test will follow this pattern; use it as your mental checklist.
Comparison tables
Assessment Data: Subjective vs. Objective
| Characteristic | Subjective Data (Symptoms/Covert) | Objective Data (Signs/Overt) |
|---|---|---|
| Definition | What patient reports; only patient can provide. | Observable, measurable, verifiable; anyone can observe. |
| Source | Patient statement only (PRIMARY). | Physical exam, vital signs, diagnostics (PRIMARY or SECONDARY). |
| How Collected | Interview, listening, patient history. | Inspection, palpation, percussion, auscultation, tests. |
| Example | Pain 8/10, dizziness, nausea, fatigue, anxiety. | BP 150/90, Temp 38.5C, SpO2 88%, cyanosis, grimacing. |
| Reliability | Valid (patient knows own experience) but may be influenced by culture, pain, cognition. | Objective, reproducible, less bias — generally more reliable for diagnosis. |
| Validation | Clarify: 'When did it start? How severe? Any triggers?' | Repeat measurement; compare to baseline; use diagnostic tests. |
Nursing Diagnosis vs. Medical Diagnosis
| Feature | Nursing Diagnosis | Medical Diagnosis |
|---|---|---|
| Definition | Clinical judgment about patient's RESPONSE to health problem. | Identification of a disease or pathological condition. |
| Made By | Nurse (independent function per RA 9173). | Physician; requires medical expertise. |
| Focuses On | Human responses, functional status, self-care ability. | Disease pathology, etiology, treatment. |
| Changes? | YES — changes as patient's response changes. | NO — remains constant (e.g., 'pneumonia' is always pneumonia). |
| Example | Ineffective airway clearance; Impaired gas exchange; Anxiety. | Pneumonia; Asthma; Myocardial infarction. |
| Scope of Care | Guides NURSING interventions (positioning, teaching, comfort). | Guides MEDICAL interventions (antibiotics, surgery, imaging). |
| Never As Etiology | NA | NEVER use medical diagnosis as etiology in nursing diagnosis (e.g., 'related to pneumonia' is WRONG). |
NANDA-I Nursing Diagnosis Types & Format
| Type | Format | Definition | Example |
|---|---|---|---|
| Actual (Problem-Focused) | PES (3-part) | Problem present NOW at assessment; supported by signs/symptoms. | Ineffective airway clearance R/T excess mucus As evidenced by wheezing, SpO2 88%. |
| Risk | PE (2-part) | Vulnerability to problem not yet present; no signs/symptoms; supported by risk factors. | Risk for falls related to age 80+ and polypharmacy. (NO 'as evidenced by') |
| Health-Promotion/Wellness | One-part or PE | Motivation to increase well-being; patient demonstrates readiness. | Readiness for enhanced nutrition management related to desire to improve diet. |
| Syndrome | PE (2-part) | Cluster of nursing diagnoses occurring together in response to single event. | Post-trauma response related to motor vehicle accident. |
Nursing Intervention Types & Scope
| Type | Definition | Nurse Authority | Example | Delegation? |
|---|---|---|---|---|
| Independent | Within nurse's scope; NO physician order required. | Nurse has full authority. | Positioning, teaching, pain assessment, wound care, encourage fluids. | NO — nurse must do (can't delegate assessment/teaching). |
| Dependent | Requires physician order; nurse executes. | MD responsible for order; nurse for execution. | Medications, catheterization, diet orders, imaging orders. | YES — can delegate task (e.g., UAP gives diet) BUT nurse supervises & verifies order. |
| Collaborative/Interdependent | Shared with other professionals; mutual goals. | Shared responsibility with team. | Physical therapy, nutrition consult, respiratory therapy, social work. | YES — coordinate with team; nurse often facilitates referral. |
Goal Achievement Outcomes & Next Steps
| Evaluation Result | Definition | Next Action | Documentation Note |
|---|---|---|---|
| Goal MET | Patient achieved or exceeded outcome criteria. | Discontinue diagnosis & interventions for that goal. | Goal achieved. Diagnosis resolved. Continue maintenance care if chronic. |
| Goal PARTIALLY MET | Patient made progress but did not fully achieve criteria. | CONTINUE interventions with possible modification; extend timeline if appropriate. | Goal progress noted. Continue current interventions. Reassess barriers. |
| Goal NOT MET | Patient made no progress or regressed; criteria not achieved. | REASSESS (find barriers); REVISE plan (change goal, intervention, or approach). | Goal not achieved. Reassessed: [reason]. Revised plan: [changes]. Restarted interventions. |
Maslow's Hierarchy Priority Ranking (HIGHEST to LOWEST)
| Level | Category | Examples | Priority |
|---|---|---|---|
| 1 (BASE) | Physiologic Needs (ABCs, survival) | Airway, breathing, circulation, oxygen, nutrition, fluids, elimination, rest, pain relief. | HIGHEST — ALWAYS address first in life-threatening situations. |
| 2 | Safety & Security | Protection from harm, safe environment, freedom from fear, stability. | HIGH — After life-threats; prevent falls, injuries, complications. |
| 3 | Love & Belonging | Social interaction, relationships, family involvement, feeling connected. | MODERATE — After safety met; foster interactions, support systems. |
| 4 | Esteem & Recognition | Self-respect, dignity, competence, autonomy, independence. | MODERATE-LOW — Promote self-care, decision-making, independence. |
| 5 (TOP) | Self-Actualization & Growth | Personal fulfillment, learning, creativity, achieving potential. | LOWEST — Address after all others; provide education, goal-setting. |
Five Rights of Delegation — Safe Task Assignment
| Right | Definition | Check | Example of WRONG Delegation |
|---|---|---|---|
| Right TASK | Task must be within delegatee's scope & training. | Is this a task UAP can do? (Not assessment, teaching, evaluation.) | Delegating wound care assessment to UAP (wrong — assessment is RN only). |
| Right CIRCUMSTANCE | Patient & environment must be safe for delegation. | Is patient stable? Is UAP available & not overloaded? | Delegating care of unstable post-op patient to UAP (wrong — unstable needs RN). |
| Right PERSON | Delegatee must be competent & trained for the task. | Does UAP have skills? Certification? Recent practice? | Delegating IV insertion to UAP (wrong — only RN/LVN trained). |
| Right DIRECTION/COMMUNICATION | Clear, specific instructions on what, when, how, expected outcome. | Did you explain the task, deadline, & expected result? Clarify expectations. | Saying 'Help Mrs. Santos with hygiene' without specifying when, what assistance, precautions (wrong — too vague). |
| Right SUPERVISION/EVALUATION | RN monitors, evaluates, & provides feedback; retains accountability. | Will you check on progress? Review result? Document? Follow up? | Delegating & then disappearing for 4 hours without checking (wrong — no supervision). |
Diagrams
ADPIE: The Five Phases of the Nursing Process
Mind map showing all five ADPIE phases, their key components, and how they interconnect in the nursing process cycle. Use this to understand the sequential and circular nature of the nursing process.
Nursing Diagnosis Formulation: Data to Diagnosis
Flowchart guiding the step-by-step process of moving from assessment data to a valid nursing diagnosis. Shows decision points for actual, risk, and wellness diagnoses, and validates that etiology is nursing-addressable.
Priority Setting: Maslow + ABC Decision Tree
Decision tree for prioritizing patient problems using Maslow's Hierarchy of Needs and the ABC framework. Follow this flowchart to rank multiple problems correctly on NLE questions.
Assessment Phase: Exam Sequence for Physical Assessment
Critical flowchart showing the DIFFERENT examination sequences for abdominal vs. all other body systems. The abdominal exam is the EXCEPTION — this distinction is a guaranteed NLE question.
Evaluation Outcomes: What Happens Next?
State diagram showing the three possible evaluation outcomes and the actions that follow each. Shows how the nursing process CYCLES — if goal not met, the process repeats through reassessment and revision.
First Action Decision: Assess vs. Intervene?
The MOST IMPORTANT decision tree for NLE success. When a question asks 'what should the nurse do FIRST?', use this flowchart. In emergencies (life-threat), INTERVENE. In stable situations, ASSESS. This principle appears in nearly every NLE exam.