Assessment
The first and most critical step. Collect subjective (what the patient tells you) and objective (what you observe/measure) data. Sources: patient, family, chart, other team members. Types: initial, focused, emergency, time-lapsed. Use head-to-toe or body-systems approach.
Nursing Diagnosis
A clinical judgment about a patient's response to actual or potential health problems. NANDA-I format: Problem + Etiology + Signs & Symptoms (PES). Three types: actual (present problem), risk (vulnerability), health promotion (desire to increase well-being). Distinct from medical diagnosis — nursing focuses on human responses.
Planning
Set SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound). Goals must be patient-centered: "Patient will demonstrate..." not "Nurse will teach..." Prioritize using Maslow and ABCs. Select nursing interventions (independent, dependent, collaborative). Create a written care plan.
Implementation
Carry out the care plan. Independent interventions: actions within nursing scope without physician order. Dependent: require physician order (medications, procedures). Collaborative: performed with other disciplines. Document every action promptly and accurately. Reassess continuously during implementation.
Evaluation
Determine if goals were met (fully, partially, or not met). Compare patient outcomes to established goals. If goals not met: reassess all previous steps. Modify the care plan as needed. Evaluation is continuous — not a final step only. "Met" = discontinue; "Partially met" or "Not met" = revise.
Important Notes
- The nursing process is cyclical, not linear — always loop back based on new assessment data.
- Documentation of each step is a legal and professional requirement.
Clinical Tips
- ADPIE mnemonic: "All Dogs Prefer Indoor Environments."
- The best nursing diagnoses are specific, prioritized, and evidence-based — avoid vague language.
Summary
ADPIE provides the systematic, scientific framework for all nursing care. Mastery of the nursing process is foundational to safe, effective, individualized patient care delivery.
