SalusPrep

Practical Nurse NCLEX®

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Clinical Judgment

ADPIE Nursing Process

Stage 2 Pressure Injury · L1

How this exercise works

Drag each nursing statement into Assessment, Diagnosis, Planning, Implementation, or Evaluation. Only one phase fits each statement — look for data vs. action cues.

Fundamental concept

How systematic ADPIE thinking supports safe practical nursing care, aligned with HHS quality initiatives.

Read: The Nursing Process: Assessment Through Evaluation →

Scenario

During skin assessment of a bedbound client, you find an open shallow ulcer on the coccyx with partial-thickness skin loss and a pink wound bed.

Nursing statements

Drag each statement into the correct ADPIE phase, or into trash if it does not belong.

Impaired skin integrity related to prolonged pressure over bony prominence.
Pressure injury will show signs of healing without increase in size within 1 week.
Document partial-thickness skin loss consistent with stage 2 pressure injury.
Reassess wound size and tissue type at next dressing change.
Cleanse wound with normal saline and apply moisture-retentive dressing per protocol.
Stage the injury as stage 4 because the client is high risk.
Measure length, width, and depth; note drainage, odor, and periwound skin.

Trash — not part of the process

0

Drop irrelevant statements here

A — Assessment

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Drop statements here

D — Diagnosis

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Drop statements here

P — Planning

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Drop statements here

I — Implementation

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Drop statements here

E — Evaluation

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Drop statements here