NLE Fundamentals of Nursing & the Nursing Process — The Nursing Process (ADPIE)Cheat Sheet
A printable cheat sheet for The Nursing Process (ADPIE), built for NLE reviewers who want one go-to reference in the final stretch. Covers formulas, key definitions, common question types, and the Professional Regulation Commission (PRC) — Board of Nursing-specific twists you will see on NLE day.
Exam context
For the Philippine Nurse Licensure Examination (PNLE), Professional Regulation Commission (PRC) — Board of Nursing tests Fundamentals of Nursing & the Nursing Process under a "Core" label, with The Nursing Process (ADPIE) in the 2nd slot across 8 chapters. NLE candidates must clear the 75% weighted average with no sub-test below 60% cut on the 2026 paper, which draws about 50 Fundamentals of Nursing & the Nursing Process questions. Date to watch: Bi-annual.
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.
Sections
Section Title
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
Term
Assessment
Example
Nurse collects vital signs, asks about pain, reviews medical history on admission.
Definition
Deliberate, systematic collection of subjective and objective data about the patient's health status; foundation of the entire nursing process.
Term
Subjective Data (Symptoms/Covert)
Example
Patient says: 'I feel dizzy,' 'My stomach hurts,' 'I haven't slept in two days.'
Definition
Information only the patient can provide; what the patient states, feels, or reports.
Term
Objective Data (Signs/Overt)
Example
BP 150/90, temperature 38.5°C, SpO₂ 88%, grimacing, cyanosis.
Definition
Observable, measurable, verifiable data obtained through physical exam or diagnostic tests.
Term
Primary Source
Example
Direct interview and physical examination of the patient.
Definition
The patient; the most reliable and preferred source of health information.
Term
Secondary Source
Example
Spouse reports patient forgets to take medications; chart shows prior HTN diagnosis.
Definition
Family, friends, medical records, other healthcare professionals, lab/diagnostic results.
Term
Cue
Example
Grimacing, BP 90/60, patient states 'I'm in pain.'
Definition
Direct observation of data (objective or subjective) the nurse perceives; a fact without interpretation.
Term
Inference
Example
Seeing grimacing + hearing 'I'm in pain' → inference: 'Patient is experiencing pain.'
Definition
The nurse's interpretation or judgment about the meaning of a cue; a conclusion drawn from data.
Term
Validation
Example
Ask patient 'On a scale of 0-10, how severe is your pain?' to validate the pain inference.
Definition
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).
Section Title
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
Term
Nursing Diagnosis
Example
Ineffective airway clearance related to excess mucus production as evidenced by adventitious breath sounds.
Definition
Clinical judgment about the patient's RESPONSE (not disease) to actual or potential health problems; independent nursing function; may change as condition changes.
Term
Medical Diagnosis
Example
Pneumonia, diabetes mellitus, myocardial infarction.
Definition
Identification of a disease or pathological condition; physician-made; remains constant throughout the illness.
Term
Actual (Problem-Focused) Diagnosis
Example
Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by SpO₂ 88%.
Definition
A problem present NOW at the time of assessment; supported by signs and symptoms.
Term
Risk Diagnosis
Example
Risk for falls related to history of falls and altered gait.
Definition
Vulnerability to a problem that HAS NOT YET OCCURRED; no signs/symptoms present; supported by risk factors only.
Term
Health-Promotion/Wellness Diagnosis
Example
Readiness for enhanced nutrition management related to desire to improve diet.
Definition
Motivation to increase well-being in an area; patient demonstrates motivation for better health.
Term
Syndrome Diagnosis
Example
Post-trauma response; relocation stress syndrome.
Definition
A cluster of nursing diagnoses occurring together in response to a single event or situation.
Term
Problem (P) — PES Format
Example
Ineffective airway clearance; Impaired skin integrity.
Definition
The nursing diagnosis label; the human response or problem statement.
Term
Etiology (E) — 'Related To'
Example
Related to decreased level of consciousness; related to immobility.
Definition
The cause or contributing factor of the problem; something the nurse CAN address (never a medical diagnosis).
Term
Signs/Symptoms (S) — 'As Evidenced By'
Example
As evidenced by wheezing, dyspnea, and SpO₂ 88%.
Definition
Cues that support the diagnosis; the data that validate the problem and etiology (ONLY in actual diagnoses).
Term
Risk Factors (Risk Diagnoses Only)
Example
Related to age over 75 years and polypharmacy.
Definition
Conditions or characteristics that increase vulnerability to a problem; replaces 'as evidenced by'.
Term
Collaborative Problems
Example
Potential complication: hemorrhage; PC: acute coronary syndrome.
Definition
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).
Section Title
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
Term
Planning
Example
Setting goal 'Patient will ambulate 3 meters without assistance by day 2' and planning mobility interventions.
Definition
Establishment of priorities, goals/outcomes, and nursing interventions; results in the patient care plan.
Term
Priority Setting
Example
Address airway before pain; address actual problem before risk diagnosis.
Definition
Ranking problems and interventions by urgency using frameworks (Maslow, ABC, actual vs risk, acute vs chronic).
Term
Goal (Long-Term Goal)
Example
Patient will demonstrate effective stress-management techniques by discharge.
Definition
Broad, general outcome expected over WEEKS to MONTHS; often relates to discharge or problem resolution.
Term
Short-Term Goal/Outcome
Example
Patient will verbalize one stress-management technique by end of shift.
Definition
Specific, measurable result expected within HOURS to DAYS; intermediate steps toward long-term goal.
Term
SMART Outcome
Example
Patient will walk 10 meters with walker by 0800 tomorrow (not 'improve mobility').
Definition
Specific (clear), Measurable (quantifiable), Attainable (achievable), Realistic (feasible), Time-bound (deadline).
Term
Nursing Intervention
Example
Assist patient to ambulate 10 meters tid; provide pain medication 30 min before activity.
Definition
A specific action or nursing order designed to help the patient achieve the outcome; may be independent, dependent, or collaborative.
Term
Independent Intervention
Example
Positioning, health teaching, encouraging fluids, assessing pain, wound care.
Definition
Nursing action within the nurse's scope and authority; does NOT require physician order.
Term
Dependent Intervention
Example
Administering medications, inserting catheter, implementing diet order.
Definition
Action carried out on physician order; nurse executes but physician is responsible for the order.
Term
Collaborative/Interdependent Intervention
Example
Physical therapy for mobility; dietary consultation for nutrition; respiratory therapy for airway.
Definition
Action done WITH other health professionals (PT, OT, nutrition, respiratory therapy); shared responsibility.
Term
Care Plan
Example
Standardized or individualized care plan in the patient's medical record or EHR.
Definition
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?).
Section Title
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
Term
Implementation
Example
Administering medication, assisting with ambulation, providing wound care, teaching patient.
Definition
Execution of the nursing care plan; carrying out planned interventions with appropriate technique, safety, and documentation.
Term
Reassessment (Before Intervention)
Example
Check BP before helping patient stand; assess pain before giving analgesic.
Definition
Quick check of patient's current status BEFORE implementing an action; conditions may have changed.
Term
Prioritization During Implementation
Example
Address critical issues first; cluster interventions to minimize patient disruption.
Definition
Sequencing interventions based on urgency, patient needs, and efficiency during shift.
Term
Documentation
Example
Charted after giving meds, after wound care, after teaching — never before.
Definition
Recording of the intervention AFTER completion, including what was done, patient response, and outcome.
Term
Delegation
Example
Delegate vital signs, hygiene, ambulation to UAP; CANNOT delegate assessment, evaluation, teaching to UAP.
Definition
Assignment of a task to an unlicensed assistive personnel (UAP) or other team member within their scope.
Term
Five Rights of Delegation
Example
Right task = UAP can take vitals; right person = trained UAP; right supervision = nurse checks result.
Definition
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).
Section Title
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
Term
Evaluation
Example
Goal: 'Walk 3m with walker by day 2.' Evaluation: Patient walked 3m independently on day 2 — GOAL MET.
Definition
Systematic determination of whether patient goals/outcomes were ACHIEVED; comparison of actual response against outcome criteria.
Term
Goal Met
Example
Patient verbalized 3 stress-management techniques (goal was 2) — goal EXCEEDED.
Definition
Patient's actual response matches or exceeds the stated outcome criteria.
Term
Goal Partially Met
Example
Patient ambulated 2 meters with walker (goal was 3) — progress made, continue intervention.
Definition
Patient made progress toward goal but did not fully achieve it; may need more time or modified approach.
Term
Goal Not Met
Example
Patient unable to ambulate; remains bedbound — GOAL NOT MET, reassess barriers.
Definition
Patient made no progress or regressed; goal criteria not achieved; requires reassessment and plan revision.
Term
Reassessment
Example
Patient can't ambulate — is it pain? weakness? fear? Reassess to find cause.
Definition
Collecting new data to understand why goal was not met; identifies barriers, changed conditions, or ineffective interventions.
Term
Plan Revision
Example
If pain is barrier → add pain control; if fear is barrier → provide education and reassurance.
Definition
Modification of the care plan based on evaluation findings; change goal, intervention, or approach.
Term
Quality of Care
Example
Were medications given on time? Was patient treated with dignity? Was goal achieved?
Definition
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.
Section Title
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
Term
Critical Thinking
Example
Nurse does not automatically assume patient in pain is 'drug-seeking' — gathers data, validates, reassesses.
Definition
Disciplined, reflective reasoning that questions assumptions, analyzes evidence, and makes sound clinical decisions.
Term
Clinical Judgment
Example
Recognizing that a patient's increased restlessness may signal pain, hypoxia, or anxiety — each requires different intervention.
Definition
Application of critical thinking to a patient situation; the ability to make the RIGHT decision in CONTEXT.
Term
Cue Recognition
Example
Increased respiratory rate + decreased SpO₂ + dyspnea = cues for hypoxia; needs airway intervention, not calm reassurance.
Definition
Identifying significant data (patterns, abnormalities, red flags) that signal a potential problem.
Term
Inference vs Cue (Clinical Judgment Skill)
Example
Cue: grimacing. Inference: 'patient is in pain.' Validate: Ask patient pain level — confirm inference.
Definition
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.
Section Title
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
Term
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).
Definition
First = immediate, urgent action (assess or intervene). Best = most effective for outcome. In stable patients, 'first' usually = assess.
Term
Actual vs. Potential Problem Priority
Example
Patient with ACTUAL pain (present) + RISK for skin breakdown (not yet present) → treat pain first.
Definition
ACTUAL (happening NOW) takes priority over RISK (might happen). An actual problem must be addressed before preventing a risk.
Term
Acute vs. Chronic Priority
Example
Patient with CHRONIC hypertension (stable) + ACUTE MI (new) → treat MI first.
Definition
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
Rows
Values
- What patient reports; only patient can provide.
- Observable, measurable, verifiable; anyone can observe.
Property
Definition
Values
- Patient statement only (PRIMARY).
- Physical exam, vital signs, diagnostics (PRIMARY or SECONDARY).
Property
Source
Values
- Interview, listening, patient history.
- Inspection, palpation, percussion, auscultation, tests.
Property
How Collected
Values
- Pain 8/10, dizziness, nausea, fatigue, anxiety.
- BP 150/90, Temp 38.5C, SpO2 88%, cyanosis, grimacing.
Property
Example
Values
- Valid (patient knows own experience) but may be influenced by culture, pain, cognition.
- Objective, reproducible, less bias — generally more reliable for diagnosis.
Property
Reliability
Values
- Clarify: 'When did it start? How severe? Any triggers?'
- Repeat measurement; compare to baseline; use diagnostic tests.
Property
Validation
Columns
- Characteristic
- Subjective Data (Symptoms/Covert)
- Objective Data (Signs/Overt)
Table Title
Assessment Data: Subjective vs. Objective
Rows
Values
- Clinical judgment about patient's RESPONSE to health problem.
- Identification of a disease or pathological condition.
Property
Definition
Values
- Nurse (independent function per RA 9173).
- Physician; requires medical expertise.
Property
Made By
Values
- Human responses, functional status, self-care ability.
- Disease pathology, etiology, treatment.
Property
Focuses On
Values
- YES — changes as patient's response changes.
- NO — remains constant (e.g., 'pneumonia' is always pneumonia).
Property
Changes?
Values
- Ineffective airway clearance; Impaired gas exchange; Anxiety.
- Pneumonia; Asthma; Myocardial infarction.
Property
Example
Values
- Guides NURSING interventions (positioning, teaching, comfort).
- Guides MEDICAL interventions (antibiotics, surgery, imaging).
Property
Scope of Care
Values
- NA
- NEVER use medical diagnosis as etiology in nursing diagnosis (e.g., 'related to pneumonia' is WRONG).
Property
Never As Etiology
Columns
- Feature
- Nursing Diagnosis
- Medical Diagnosis
Table Title
Nursing Diagnosis vs. Medical Diagnosis
Rows
Values
- 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%.
Property
Actual (Problem-Focused)
Values
- 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')
Property
Risk
Values
- One-part or PE
- Motivation to increase well-being; patient demonstrates readiness.
- Readiness for enhanced nutrition management related to desire to improve diet.
Property
Health-Promotion/Wellness
Values
- PE (2-part)
- Cluster of nursing diagnoses occurring together in response to single event.
- Post-trauma response related to motor vehicle accident.
Property
Syndrome
Columns
- Type
- Format
- Definition
- Example
Table Title
NANDA-I Nursing Diagnosis Types & Format
Rows
Values
- 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).
Property
Independent
Values
- 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.
Property
Dependent
Values
- 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.
Property
Collaborative/Interdependent
Columns
- Type
- Definition
- Nurse Authority
- Example
- Delegation?
Table Title
Nursing Intervention Types & Scope
Rows
Values
- Patient achieved or exceeded outcome criteria.
- Discontinue diagnosis & interventions for that goal.
- Goal achieved. Diagnosis resolved. Continue maintenance care if chronic.
Property
Goal MET
Values
- 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.
Property
Goal PARTIALLY MET
Values
- 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.
Property
Goal NOT MET
Columns
- Evaluation Result
- Definition
- Next Action
- Documentation Note
Table Title
Goal Achievement Outcomes & Next Steps
Rows
Values
- Physiologic Needs (ABCs, survival)
- Airway, breathing, circulation, oxygen, nutrition, fluids, elimination, rest, pain relief.
- HIGHEST — ALWAYS address first in life-threatening situations.
Property
1 (BASE)
Values
- Safety & Security
- Protection from harm, safe environment, freedom from fear, stability.
- HIGH — After life-threats; prevent falls, injuries, complications.
Property
2
Values
- Love & Belonging
- Social interaction, relationships, family involvement, feeling connected.
- MODERATE — After safety met; foster interactions, support systems.
Property
3
Values
- Esteem & Recognition
- Self-respect, dignity, competence, autonomy, independence.
- MODERATE-LOW — Promote self-care, decision-making, independence.
Property
4
Values
- Self-Actualization & Growth
- Personal fulfillment, learning, creativity, achieving potential.
- LOWEST — Address after all others; provide education, goal-setting.
Property
5 (TOP)
Columns
- Level
- Category
- Examples
- Priority
Table Title
Maslow's Hierarchy Priority Ranking (HIGHEST to LOWEST)
Rows
Values
- 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).
Property
Right TASK
Values
- 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).
Property
Right CIRCUMSTANCE
Values
- 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).
Property
Right PERSON
Values
- 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).
Property
Right DIRECTION/COMMUNICATION
Values
- 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).
Property
Right SUPERVISION/EVALUATION
Columns
- Right
- Definition
- Check
- Example of WRONG Delegation
Table Title
Five Rights of Delegation — Safe Task Assignment
Previous chapter
Introduction to Professional Nursing & Nursing Theories
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Vital Signs & Basic Physiologic Monitoring
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