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?
Which intervention is an independent (nurse-initiated) intervention that the RN can perform without a provider's order?
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?