2.1 The Nursing Process (ADPIE) in the Acute Situation

The Nursing Process (ADPIE) in the Acute Situation

RCSI lists Nursing process in the acute situation as an OSCE station group in its own right, and publishes its current examples: type 1 diabetes, neurovascular assessment, delirium, deep vein thrombosis, acute urinary tract infection, stoma, and post-operative bleed. Its reading list points to the five stages of the nursing process, ADPIE.

That framing matters. These stations are not primarily testing whether you can perform a procedure - they are testing whether you can think like a nurse in a structured way when a patient's condition changes. NMBI Domain 2, nursing practice and clinical decision-making, is written in exactly this shape: assess nursing and health needs (2.1), plan and prioritise person-centred care (2.2), deliver nursing skills and interventions (2.3), evaluate outcomes and reassess (2.4), and utilise clinical judgment (2.5).

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The Five Stages

        +-------------------+
        |   A: ASSESSMENT   | <---------------------+
        +---------+---------+                       |
                  v                                 |
        +-------------------+                       |
        |   D: DIAGNOSIS    |                       |
        +---------+---------+                       |
                  v                                 |
        +-------------------+                       |
        |   P: PLANNING     |                       |
        +---------+---------+                       |
                  v                                 |
        +-------------------+                       |
        | I: IMPLEMENTATION |                       |
        +---------+---------+                       |
                  v                                 |
        +-------------------+                       |
        |  E: EVALUATION    | ----------------------+
        +-------------------+   goal not met -> reassess

The arrow back from evaluation is the part candidates drop. A station that ends with the intervention and no statement of how the outcome will be judged has completed four stages out of five.

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Nursing Diagnosis versus Medical Diagnosis

This distinction is worth getting exactly right, because it is the clearest marker of whether a candidate is thinking as a nurse or as a doctor's assistant.

• A medical diagnosis names the disease: deep vein thrombosis, acute urinary tract infection, type 1 diabetes mellitus. It is made by a medical practitioner and generally does not change through the admission.
• A nursing diagnosis names the human response to that condition, and it is something nursing intervention can change: acute pain related to venous obstruction, evidenced by a pain score of 7/10 and calf tenderness.

The standard structure is PES:

A risk diagnosis has no "S" element - the problem has not happened yet - so it is written as problem related to risk factor.

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Planning: SMART Goals and Prioritisation

Goals belong to the patient, not the chart. "Encourage fluids" is a nursing action; "the patient will drink 1500 mL of oral fluid in 24 hours" is a goal.

SMART: Specific, Measurable, Achievable, Relevant, Time-bound.

Prioritising is itself examinable. A defensible order of reasoning:

1. Life-threatening first - anything in the ABCDE sequence, an INEWS trigger, active bleeding.
2. Safety next - falls risk, an unsafe environment, a drug about to be given without an allergy check.
3. Then the patient's own stated priority, which may be pain, nausea or dignity.
4. Then longer-term needs - education, discharge planning, referrals.

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Worked Example: A Post-Operative Bleed

RCSI lists post-operative bleed as a current example, so here is the cycle applied to it.

• Assessment. Patient is day 1 after a total hip replacement. Wound dressing is heavily strike-through, the drain has 350 mL in the last hour, the pulse is 118, systolic BP 92, respiratory rate 24, patient is pale, clammy and anxious. INEWS is calculated and totals 9, with systolic BP scoring 3.
• Diagnosis. Deficient fluid volume related to post-operative haemorrhage, as evidenced by tachycardia, hypotension, heavy wound strike-through and 350 mL drain loss in one hour.
• Planning. Goal: systolic BP above 100 mmHg and heart rate below 100 within 30 minutes of intervention; bleeding controlled; the patient is not left alone.
• Implementation. Escalation is immediate - an aggregate of 7 or more is an emergency response requiring the Registrar to review immediately with the Consultant informed, and a single parameter scoring 3 requires the SHO to review immediately, with the Registrar contacted if there is no response. Apply firm pressure over the wound, keep the patient flat with legs elevated if tolerated, give oxygen as prescribed, secure large-bore IV access, take bloods including a group and crossmatch, commence a fluid challenge as prescribed, handover using ISBAR, and record everything.
• Evaluation. Repeat the full observation set half-hourly as the emergency tier requires, recalculate INEWS, measure ongoing drain loss, and reassess whether the goal was met. If the blood pressure has not responded, the cycle restarts and critical care escalation follows.

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Worked Example: Acute Urinary Tract Infection in an Older Adult

• Assessment. An 82-year-old woman, usually orientated, is newly confused and has been incontinent overnight. Temperature 37.9, heart rate 104, respiratory rate 22, BP 112/70, 4AT completed and scores 5. Urine is cloudy and offensive. Dipstick and a clean-catch specimen are obtained.
• Diagnosis. Acute confusion related to suspected urinary tract infection, as evidenced by a 4AT score of 5 and a documented change from her usual orientation. A second diagnosis of risk of falls related to acute confusion and unfamiliar environment runs alongside it.
• Planning. Goals: infection identified and treated; the patient sustains no fall; cognition returns to her documented baseline before discharge.
• Implementation. Escalate for medical review and antimicrobials; encourage oral fluids and record intake and output; orientate frequently, ensure glasses and hearing aids are in place, keep the environment calm and well lit; complete a falls risk assessment and put the bed at its lowest with the call bell in reach; avoid an indwelling catheter unless clinically necessary.
• Evaluation. Repeat the 4AT; review the fluid balance chart; check whether the observations have normalised; confirm no falls occurred; reassess before discharge.

Note what the cycle prevents here: treating "confusion" as the diagnosis and sedating the patient, rather than treating the infection that caused it.

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Doing ADPIE Inside 10 Minutes

You will not write a care plan at the station. What you must do is make each stage audible:

1. "I am going to assess her systematically using ABCDE and then review her charts."
2. "My nursing concern is acute confusion related to a likely urinary tract infection, with an associated falls risk."
3. "My immediate goals are to have her reviewed by the doctor within the hour and to keep her safe from falling in the meantime."
4. Carry out the actions.
5. "I will repeat her observations and her 4AT, and I will document and hand over using ISBAR."

That is the nursing process delivered in five sentences and a set of hands-on actions - and it is what the station is scored against.