NCLEX Review Guide: Nursing Process & Documentation

Five-Step Nursing Process (ADPIE)

• Assessment: Systematic collection of subjective and objective data through observation, interview, and physical examination to establish baseline patient status.
• Diagnosis: Analysis of assessment data to identify actual or potential health problems using NANDA-approved nursing diagnoses with specific etiology and defining characteristics.
• Planning: Development of measurable, realistic, and time-specific goals with evidence-based interventions prioritized by Maslow's hierarchy and ABC priorities.
• Implementation: Execution of planned nursing interventions including direct care, teaching, coordination, and collaboration with healthcare team members.
• Evaluation: Systematic review of patient outcomes against established goals to determine effectiveness of interventions and need for plan modifications.

Priority Frameworks

• ABC Priority: Airway, Breathing, Circulation - always address life-threatening issues first, with airway obstruction taking precedence over all other concerns.
• Maslow's Hierarchy: Physiological needs (oxygen, food, water, elimination) → Safety → Love/Belonging → Esteem → Self-actualization priorities guide nursing interventions.
• Acute vs Chronic: Acute conditions requiring immediate intervention take priority over stable chronic conditions that can be managed with routine care.

Legal Documentation Standards

• Accuracy & Completeness: Document factual, objective observations using specific measurements and direct quotes rather than subjective interpretations or assumptions.
• Timeliness: Record entries as close to the time of occurrence as possible, using current date and time with appropriate signatures and credentials.
• Legibility & Permanence: Use black ink for handwritten entries, avoid erasures or white-out, and draw single line through errors with initials and date.

Types of Nursing Interventions

1. Independent Interventions: Actions within nursing scope that don't require physician orders (positioning, teaching, comfort measures, emotional support)
2. Dependent Interventions: Actions requiring physician orders or protocols (medication administration, diagnostic procedures, specific treatments)
3. Collaborative Interventions: Actions performed with other healthcare team members (care coordination, interdisciplinary planning, referrals)

Outcome Evaluation Process

• Goal Achievement Assessment: Compare actual patient outcomes with expected outcomes using measurable criteria established during planning phase.
• Intervention Effectiveness: Analyze whether nursing actions produced desired results and identify factors that enhanced or hindered goal attainment.
• Plan Modification: Revise nursing diagnoses, goals, or interventions based on evaluation findings to ensure continued progress toward optimal patient outcomes.