9.1 Nursing Care Planning
Key Takeaways
ADPIE — Assessment, Diagnosis, Planning, Implementation, Evaluation — is the five-step nursing process the ANCC exam uses to structure planning and evaluation questions
A measurable outcome follows SMART criteria and is written from the patient's perspective: "Patient will walk 50 feet with a walker by postoperative day 2"
Independent interventions (repositioning, teaching) require no provider order; dependent interventions (medications) do; collaborative interventions engage the interprofessional team
When an outcome is unmet, the nurse reassesses and revises the plan — never simply abandons the goal or blames the patient
Prioritize with airway-breathing-circulation first, then acute over chronic and actual problems over risk problems
The Nursing Process: ADPIE
The nursing process is the systematic, patient-centered, goal-oriented framework that organizes everything a registered nurse (RN) does. The American Nurses Association (ANA) codifies it as five steps, remembered by the mnemonic ADPIE:
| Step | Core Question | Key Activities |
|---|---|---|
| Assessment | What data do I have? | Collect subjective and objective data; interview, physical exam, chart review |
| Diagnosis | What is the problem? | Analyze data; formulate a nursing diagnosis (problem-focused, risk, or health promotion) |
| Planning | What do I want to achieve, and how? | Prioritize problems; write measurable goals/outcomes; select evidence-based interventions |
| Implementation | Am I doing the plan? | Perform or delegate interventions; coordinate care; document |
| Evaluation | Did it work? | Compare patient response to outcomes; revise the plan |
Exam questions frequently disguise a phase question: if the stem says the nurse "sets a goal with the patient," that is planning; if it says the nurse "checks whether the goal was met," that is evaluation.
Nursing Diagnosis Basics
A nursing diagnosis (NANDA International, or NANDA-I, terminology) describes a human response the RN is licensed to treat independently — it is not a medical diagnosis. "Impaired Gas Exchange" is a nursing diagnosis; "pneumonia" is a medical diagnosis. Three types appear on exams:
- Problem-focused (actual): a validated current problem, written in PES format — Problem, Etiology (related to), Signs/Symptoms (as evidenced by). Example: "Acute Pain related to surgical incision as evidenced by patient report of 8/10 pain and guarding."
- Risk: a vulnerability with no signs yet — two-part statement, never "as evidenced by." Example: "Risk for Falls related to new opioid therapy."
- Health promotion: readiness to improve health. Example: "Readiness for Enhanced Nutrition."
Rule to remember: a risk diagnosis can never have an "as evidenced by" clause because there are no defining characteristics yet.
Writing Measurable Goals and Outcomes
A goal is the broad aim; an outcome is the specific, observable, measurable change in patient status used to judge whether the goal was met. Exam-ready outcomes are SMART:
- Specific — one behavior, clearly stated
- Measurable — includes a quantity, distance, or scale
- Achievable — realistic for this patient's condition and resources
- Relevant (patient-centered) — written as what the patient will do, not what the nurse will do
- Time-bound — a date, shift, or postoperative day
Short-term outcomes are achievable within hours to days (a hospital shift or a week); long-term outcomes span weeks to months (weight loss over 3 months, independent insulin self-administration by 6 weeks after diagnosis).
| Weak (not measurable) | Strong (SMART) |
|---|---|
| "Patient will feel less pain" | "Patient will report pain ≤3/10 within 30 minutes of analgesic administration" |
| "Patient will understand insulin" | "Patient will demonstrate correct insulin self-injection technique before discharge on 8/5" |
| "Nurse will encourage ambulation" | "Patient will walk 50 feet in the hallway with a walker by postoperative day 2" |
The third weak example fails because it describes a nursing action, not a patient outcome — a classic exam distractor.
Selecting Interventions
Evidence-based interventions should link directly to the etiology of the diagnosis (treat the "related to" factor). Classify every intervention one of three ways:
| Type | Definition | Examples |
|---|---|---|
| Independent (nurse-initiated) | Within RN scope; no provider order needed | Repositioning every 2 hours, patient teaching, encouraging coughing and deep breathing, range-of-motion exercises, fall precautions |
| Dependent (provider-initiated) | Requires a provider's order | Administering furosemide 40 mg IV, inserting an indwelling catheter, applying a prescribed diet order |
| Collaborative (interdependent) | Carried out with other disciplines | Physical therapy for ambulation, respiratory therapy for incentive spirometry instruction, dietitian consult for heart-healthy diet, wound care team |
Standardized languages such as the Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) link diagnoses to evidence-based interventions and outcomes — know that they exist and what they are for.
Evaluation and Modifying the Plan
Evaluation compares the patient's actual response to the stated outcome, with three possible determinations:
- Outcome met — continue or resolve the diagnosis
- Outcome partially met — continue the plan, possibly extending the time frame
- Outcome not met — reassess and revise: Was the diagnosis correct? Was the outcome realistic? Was the etiology accurate? Were the interventions implemented as written?
The exam traps here: never select an answer that discontinues a goal simply because it was unmet, and never blame the patient ("noncompliant") without reassessing barriers. The correct action is to reassess and modify the plan — the nursing process is circular, not linear.
Prioritizing the Care Plan
When multiple problems compete, apply these rules in order:
- ABCs first — airway, breathing, circulation always outrank everything else.
- Maslow's hierarchy — physiological needs before safety, then love/belonging, esteem, self-actualization.
- Acute over chronic — a new onset of chest pain outranks chronic osteoarthritis pain.
- Actual problems over risk problems — an actual bleed outranks "risk for injury," unless the risk is imminent and life-threatening (e.g., risk for airway compromise in anaphylaxis).
- Least invasive first when choosing among interventions of equal priority.
Concept Maps and Critical Pathways
- A concept map is a visual diagram linking a patient's problems, assessment data, and interventions to show relationships — a clinical-reasoning teaching tool rather than a legal document.
- A critical pathway (also called a clinical pathway or care map) is a standardized, multidisciplinary, time-sequenced plan for a predictable diagnosis-related group — for example, the day-by-day expected course after total hip arthroplasty. Deviations from the pathway are called variances and must be documented and addressed.
- Standardized care plans are pre-written templates for common diagnoses; they must still be individualized to the patient — adding patient-specific outcomes and deleting irrelevant items — or they fail the planning standard.
A nurse is planning care for a patient on postoperative day 1 after total hip arthroplasty. Which outcome statement is written correctly?
The patient will understand the importance of ambulation before discharge
The nurse will encourage the patient to ambulate in the hallway three times daily
The patient will walk 50 feet in the hallway with a walker by postoperative day 2
The patient will have improved mobility within the next few weeks
Which intervention is an independent (nurse-initiated) intervention that the RN can perform without a provider's order?
Repositioning a patient every 2 hours to prevent pressure injury
Administering furosemide 40 mg intravenously for pulmonary congestion
Administering acetaminophen 650 mg orally for fever per a standing order
Placing the patient on a prescribed 2-gram sodium diet
During evaluation, a nurse finds that a patient has not met the outcome of ambulating 100 feet twice daily by postoperative day 3. What is the most appropriate nursing action?
Discontinue the ambulation goal, since the patient has demonstrated it is unrealistic
Document the outcome as unmet and remove the activity diagnosis from the care plan
Report the patient to the provider as noncompliant with the treatment plan
Reassess barriers such as pain control and revise the plan with a realistic time frame
Sections you finish are checked off in the contents.