The Nursing Process & Clinical Reasoning (ADPIE)
Master the five-step nursing process — the foundation of all nursing practice and NCLEX-style reasoning. Covers ADPIE, NANDA nursing diagnoses, priority-setting frameworks, the Clinical Judgment Model, and delegation principles.
Visual learning
ADPIE clinical judgment loop
Use assessment, diagnosis, planning, implementation, and evaluation as a repeating reasoning cycle.
A
Collect data
D
Name response
P
Set priority
I
Do safely
E
Reassess
- 1
Assessment
Collect subjective and objective data.
- 2
Diagnosis
Cluster data into patient responses and nursing problems.
- 3
Planning
Set priorities, outcomes, and interventions.
- 4
Implementation
Carry out safe interventions and document.
- 5
Evaluation
Compare outcomes with goals and revise the plan.
Clinical connection
ADPIE helps a beginner decide whether the scenario asks for data collection, problem identification, goal setting, action, or reassessment.
Assessment — The Foundation of Everything
Gathering complete, accurate data before any clinical decision
ADPIE — The Nursing Process
The nursing process is a systematic, evidence-based framework nurses use to deliver patient-centered care. It has five steps — Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE). The process is cyclical, not linear: after evaluation, the nurse reassesses and adjusts. Every step depends on the one before it. If assessment data is incomplete, the nursing diagnosis will be inaccurate. If the diagnosis is wrong, the plan will miss the target.
Assessment — What, How, and Why
Assessment — Self-Check
1/2A patient says 'I feel like my heart is racing.' This is:
Nursing Diagnosis
Identifying patient problems nurses are qualified to treat
NANDA Nursing Diagnoses — PES Format
A nursing diagnosis (NANDA) identifies a patient's actual or potential health problem that nurses are qualified and licensed to treat. It is different from a medical diagnosis (which identifies disease). The three-part PES format: Problem (the nursing diagnosis label) + Etiology (related to — the cause or contributing factor) + Signs and Symptoms (as evidenced by — the assessment data that supports it). Example: Acute Pain related to surgical incision as evidenced by patient reporting 8/10 pain and guarding the abdomen.
Actual Nursing Diagnosis
Problem exists NOW. Evidence is present. Three parts: problem + etiology + evidence.
Impaired Gas Exchange related to pneumonia as evidenced by SpO2 91% and crackles on auscultation.
Risk Nursing Diagnosis
Problem does NOT exist yet but evidence suggests vulnerability. Two parts: problem + risk factors (no 'as evidenced by').
Risk for Falls related to altered gait, polypharmacy, and post-operative weakness.
Wellness/Promotion Diagnosis
Patient is functioning well and desires a higher level of wellness. Begins with 'Readiness for enhanced...'
Readiness for Enhanced Breastfeeding as evidenced by mother's expressed desire and successful latching.
Nursing Diagnosis — Self-Check
1/2A nursing diagnosis MOST differs from a medical diagnosis in that a nursing diagnosis:
Planning — Setting Goals and Selecting Interventions
SMART goals and evidence-based nursing interventions
SMART Goal Criteria for Nursing Outcomes
Planning — Self-Check
1/1Which goal statement is MOST consistent with SMART criteria?
Priority-Setting Frameworks
Maslow, ABC, and safety — applied to clinical decision-making
ABC Priority Hierarchy
Maslow's Hierarchy — Applied to Nursing
Priority Setting — Self-Check
1/1A nurse has four patients. Which patient should be assessed FIRST?
Clinical Judgment Model (NGN) & Delegation
Next Generation NCLEX thinking and safe task assignment
NCSBN Clinical Judgment Model — 6 Cognitive Skills
The Five Rights of Delegation
The Five Rights of Delegation guide safe task assignment: Right Task (can this task be delegated?), Right Circumstance (is the patient stable enough?), Right Person (does this person have the competency?), Right Direction (are instructions clear and complete?), Right Supervision (will you monitor and evaluate outcomes?). RNs can delegate selected tasks to LPNs/RPNs and UAPs — but cannot delegate assessment, nursing diagnosis, planning, or evaluation. The delegating nurse retains accountability.
Nursing Process — Comprehensive Quiz
1/4A nurse completes a head-to-toe assessment and formulates a nursing diagnosis of 'Impaired Skin Integrity.' The nurse then creates a wound care plan and begins dressing changes. Which step of the nursing process is being performed LAST in this sequence?
Assessment — The Foundation of Safe Care
Systematic data collection, primary vs secondary sources, and Gordon's Functional Health Patterns
Subjective vs Objective Data
What the patient tells you — only they can feel it. "Pain 8/10." "I feel nauseated." "Everything is spinning." Documented in the patient's own words, in quotation marks.
What you observe, measure, or test. BP 90/60 mmHg, RR 22/min, SpO2 89%, skin diaphoretic. Documented factually without interpretation.
Primary vs Secondary Data Sources
The patient — most reliable when conscious, alert, and oriented. Always attempt to obtain history directly from the patient first.
Family members, caregivers, medical records, other healthcare providers, medication lists. Essential when patient cannot communicate (altered LOC, language barrier, cognitive impairment).
Health History Components
Physical Examination Sequence: IPPA
Exception: Abdominal assessment uses IAPP — auscultation before palpation/percussion to avoid altering bowel sounds.
Gordon's 11 Functional Health Patterns
A systematic framework organizing assessment data across all dimensions of human functioning. Used to identify both actual problems and risk states.
How One Missed Assessment Finding Cascades to Patient Harm
One missed assessment finding can cascade into a chain of clinical failures. If a nurse fails to detect that a patient's SpO2 has dropped from 97% to 89%, she may not identify the nursing diagnosis of Impaired Gas Exchange. Without the correct diagnosis, the care plan addresses the wrong problem. Interventions (turning the patient for comfort rather than repositioning for oxygenation) fail to address the real issue. Evaluation finds 'no improvement' without understanding why. The error originated in step one — incomplete assessment. This is why assessment is not just the first step; it is the foundation every subsequent step depends upon.
Assessment Foundations — Self-Check
1/4A nurse documents: 'Patient reports pain as 8/10, describes it as burning and constant in the right lower quadrant.' This is:
Nursing Diagnosis (NANDA-I) — In Depth
Structure, types, priority-setting, and common pitfalls
Nursing vs Medical Diagnosis — The Critical Distinction
Medical diagnosis: Pneumonia (disease process identified by physician). Nursing diagnosis: Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by SpO2 88%, RR 26, use of accessory muscles, and patient reports shortness of breath. The nursing diagnosis addresses what nurses can actually treat: the human response to the disease — impaired breathing — not the disease itself. Both diagnoses are necessary. They are complementary, not competing. A nurse who only uses the medical diagnosis to guide care will miss the nursing-specific interventions that address oxygenation, positioning, breathing technique, and anxiety.
NANDA-I Diagnosis Structure: Problem + Etiology + AEB
Full NANDA Example:
"Impaired Gas Exchange
related to alveolar-capillary membrane changes
as evidenced by SpO2 88%, RR 26/min, use of accessory muscles, and patient reports shortness of breath at rest."
Problem (P)
The NANDA label — the human response. Describes WHAT is wrong from nursing's perspective.
Etiology (E) — 'Related To'
The cause or contributing factor. This is WHAT THE NURSE CAN TARGET with interventions.
Defining Characteristics — 'AEB'
The evidence. Objective and subjective data that confirm the problem exists. REQUIRED for actual diagnoses.
Types of NANDA-I Diagnoses
Impaired Urinary Elimination r/t UTI AEB burning on urination and frequency
Problem is present NOW. All three parts required.
Risk for Infection r/t indwelling urinary catheter
Vulnerable to developing the problem. NO 'as evidenced by' — problem doesn't exist yet.
Readiness for Enhanced Nutrition
Patient is functioning adequately but wants to improve. No AEB or etiology needed.
Chronic Pain Syndrome (addresses multiple concurrent nursing diagnoses)
A cluster of nursing diagnoses that occur together and are best addressed as a unit.
Priority-Setting Among Nursing Diagnoses
When a patient has multiple nursing diagnoses (common), prioritize using: (1) Life threat — airway, breathing, circulation first. (2) Maslow hierarchy — physiological needs before psychosocial. (3) Patient values — what matters most to the patient within the safe parameters.
Common NANDA-I Writing Errors to Avoid
WRONG: "Patient has pneumonia"
Why: That is a medical diagnosis — describes a disease, not a nursing-treatable human response
WRONG: "Impaired Gas Exchange r/t patient smoked for 30 years"
Why: The etiology blames the patient — never place blame on the patient in a nursing diagnosis
WRONG: "Risk for Falls as evidenced by unstable gait"
Why: Risk diagnoses have no 'as evidenced by' — the problem doesn't exist yet. Use 'related to risk factors of'
WRONG: "Alteration in comfort"
Why: Vague, outdated label — use specific current NANDA terminology like Acute Pain or Chronic Pain
NANDA-I Nursing Diagnosis — Self-Check
1/4Which of the following is correctly written as a NANDA-I nursing diagnosis?
Planning, Implementation, and Evaluation
SMART outcomes, intervention types, and closing the ADPIE loop
Planning to Implementation — From Goal to Action
Planning sets the destination; implementation is the journey. A well-written nursing care plan specifies patient-centered outcomes (what the patient will do or achieve), not nurse-centered activities. 'Nurse will position patient at 30 degrees' is a nursing activity, not an outcome. 'Patient will maintain SpO2 of 94% or greater on room air within 2 hours' is a patient outcome — observable, measurable, and time-bound. When implementing interventions, evidence-based practice guides every action: positioning, breathing exercises, medication administration, and patient education all have evidence bases that justify their inclusion in the plan.
Writing Patient Outcome Statements
Outcome statements have four components: Subject (who — always the patient) + Verb (observable action) + Condition (under what circumstances) + Criterion (how well or by when).
Example outcome statement:
Subject: "The patient"
Verb: "will demonstrate"
Condition: "correct use of incentive spirometer"
Criterion: "achieving 1500 mL inspiratory volume before discharge."
Full: "The patient will demonstrate correct use of incentive spirometer achieving 1500 mL inspiratory volume before discharge."
Types of Nursing Interventions
Independent Interventions
Nurse initiates without a physician order — within independent nursing scope.
Examples: Repositioning, encouraging oral fluids, deep breathing exercises, patient education, therapeutic communication, fall prevention measures, skin assessment.
Dependent Interventions
Requires a physician or advanced practice provider order to perform.
Examples: Administering medications, performing wound care per protocol, drawing blood for labs, inserting a urinary catheter, initiating IV therapy.
Collaborative (Interdependent) Interventions
Planned and implemented jointly with other healthcare team members.
Examples: Dietary consult for nutritional planning, PT referral for mobility, social work for discharge planning, respiratory therapy for ventilator management, pharmacy for medication reconciliation.
ADPIE — All Five Steps with Nursing Actions
Planning, Implementation, Evaluation — Self-Check
1/3A nurse writes the outcome: 'Patient will ambulate in the hallway.' This outcome is MISSING which SMART component?
Delegation and Priority-Setting in Clinical Practice
Five Rights of Delegation, who can receive delegation, and NCLEX clinical judgment traps
The Five Rights of Delegation (NCSBN)
Tasks RN Can Delegate to UAP
Tasks NEVER Delegated — RN Only
NCLEX Clinical Judgment Traps — Delegation Questions
Trap 1: "Which patient do you see FIRST?"
Always choose the most unstable, acutely deteriorating, or potentially life-threatening patient. Active airway compromise beats post-op pain 7/10 every time.
Trap 2: "What do you do FIRST?"
Assessment precedes intervention UNLESS there is an immediate life threat (e.g., patient has no pulse → start CPR). If the situation is NOT immediately life-threatening, assess first to gather data before acting.
Trap 3: "They are licensed, so I can delegate anything"
Licensure does not equal competency for every task. You can only delegate to someone who has demonstrated competency for that specific task in that specific setting. An LPN licensed in another state may not have demonstrated competency at your facility.
Trap 4: "I delegated it, so it is no longer my responsibility"
WRONG. The delegating RN retains accountability for the delegated task at all times. You must supervise, be available, evaluate the outcomes, and intervene if the delegatee reports a problem or performs incorrectly.
Delegation Principles — Self-Check
1/4An RN needs to delegate tasks at the beginning of a shift. Which task is APPROPRIATE to delegate to a UAP?
Practice Care Plan Construction
Build a complete ADPIE care plan from a clinical scenario
Care plan construction is a core competency in every nursing program. A care plan applies all five ADPIE steps to one patient scenario — from collecting assessment data, to identifying a nursing diagnosis, to writing SMART goals, selecting interventions, and evaluating outcomes. This lesson walks through a complete guided care plan step by step.
Clinical Scenario — Mr. Santos, 72 years old
Mr. Santos was admitted following a right total hip replacement two days ago. He reports pain 7/10 in the right hip with movement, rates it 3/10 at rest. He has not ambulated since surgery. He states: 'I'm afraid I'll fall if I try to walk.' Vital signs: BP 126/78, HR 82, RR 16, Temp 37.1°C, SpO2 96%. Lungs clear. Right hip incision intact with small amount of serosanguineous drainage. He is on scheduled acetaminophen and PRN hydromorphone. He lives alone and is concerned about managing at home after discharge.
Step-by-Step Care Plan — Apply ADPIE to Mr. Santos
Documentation Example — Nursing Note for Mr. Santos (SOAP Format)
Care Plan Construction — Self-Check
1/2In Mr. Santos's care plan, which nursing intervention requires a physician order to implement?
Nursing Process — Comprehensive Final Quiz
10 questions spanning all five modules
Nursing Process — All Modules Final Assessment
1/10A nurse is admitting a 68-year-old patient with shortness of breath. The patient says 'I can't catch my breath and my ankles have been swollen for a week.' Vital signs: RR 24, SpO2 91%, BP 158/96, HR 102. Which data is SUBJECTIVE?
Pre-nursing comprehensive review
1/20Which organelle contains its own DNA and is inherited exclusively from the mother?