Professional Documents
Culture Documents
Chapter 6
KEY TERMS
Analysis—The examination of data and identification of Nursing Outcomes Classification (NOC) system—A
client problems, nursing diagnoses, and/or needs; it standardized classification of client outcomes that
is the second step of the nursing process respond to nursing interventions
Assessment—The ongoing, systematic collection, Nursing process—A critical thinking framework that
validation, and documentation of data; it is the first involves assessing and analyzing human responses to
step of the nursing process plan and implement nursing care that meets client
Critical thinking—A cognitive strategy by which one needs as evidenced by the evaluation of client
reflects on and analyzes personal thoughts, actions, outcomes; consists of assessment, analysis, planning,
and decisions implementation, and evaluation
Data—Collected information Objective data (also known as signs)—Overt,
Delegate—Transferring the authority to act to another measurable assessments collected via the senses
while retaining accountability for the outcome Outcome—A specific desired change in a client’s
Evaluation—The comparison of planned expected condition as a result of nursing interventions
outcomes with a client’s actual outcomes to Planning—The identification of goals and/or outcomes
determine whether client needs have been met; it is and nursing interventions that address client
the fifth step of the nurse process problems, nursing diagnoses, or needs; it is the third
Goal—A broad statement about the status one expects a step of the nursing process
client to achieve Priority—Something ranked highest in terms of
Implementation—The organization, management, and importance or urgency
implementation of planned nursing actions that Subjective data (also known as symptoms)—Covert
involves thinking and doing; it is the fourth step of information, such as feelings, perceptions, thoughts,
the nursing process sensations, or concerns, that are shared by the client
Nonverbal data—Observable behavior transmitting a and can be verified only by the client
message without words Verbal data—Spoken or written messages
Nursing Interventions Classifications (NIC) system—A
standardized classification of nursing interventions
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I. Critical Thinking
Critical thinking involves mental strategies associated
with problem-solving, decision making, use of the scien-
tific method, and diagnostic reasoning. When critical
thinking is applied to the practice of nursing, it is called
the nursing process. Before one can employ the nursing
process, consisting of assessment, analysis, planning,
implementation/intervention, and evaluation, one must
first have a better understanding of what is critical think-
ing. The helix of critical thinking schematically represents
the concept of critical thinking (Fig. 6.1). The helix
consists of cognitive and personal competencies (Fig. 6.2).
The helix of critical thinking can be applied to the nursing
process (Fig. 6.3).
A. Introduction to critical thinking
1. Critical thinking is a cognitive strategy by which
you reflect on and analyze your thoughts, actions,
and decisions; it requires internal cognitive and
personal competencies (see Fig. 6.2).
2. Cognitive competencies.
a. Cognitive competencies are the intellectual or
reasoning processes used when thinking and
include such skills as the ability to understand,
analyze, interpret, correlate, investigate, com-
pare and contrast, categorize, determine signifi-
cance, query evidence, establish priorities, make
inferences, and determine consequences, to
name a few.
b. The more internal cognitive competencies a per-
son can bring to the thinking process, the more
successful a person will be at thinking critically.
3. Personal competencies.
a. Personal competencies are the attitudes and
characteristics that are associated with suc-
cessful critical thinkers, such as being an
independent thinker, open-minded, imagina-
tive, disciplined, committed, accountable,
inquisitive, confident, reflective, objective,
intuitive, rational, curious, honest, and moral,
to name a few.
b. The more personal competencies a person can
bring to the thinking process, the more success-
ful a person will be at thinking critically.
B. Maximize your critical thinking ability
1. Self-analysis: The competencies listed previously
are just a few of the competences in each category.
Make a list or your own competencies. This will
enable you to identify additional skills and abilities
that you need to work on acquiring.
2. Techniques to improve critical thinking. Fig 6.1 The helix of critical thinking. (From Nugent and Vitale
a. Study your textbooks and other resources. A [2015]. Fundamentals success, 4th ed. Philadelphia: F. A. Davis
strong knowledge base is essential to thinking Company, with permission.)
critically.
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III. Assessment
Assessment, the first step of the nursing process, is the
ongoing, systematic collection, validation, and documen-
tation of data. Data are information. Nursing assessment
should be comprehensive, holistic, and accurate so that
it provides all the necessary information about a client.
In addition, it should reflect the client’s responses to a
health problem and stressors, not disease processes.
Adequate assessment depends on collecting data using
various methods, collecting both subjective and objective
data, verifying that data are accurate, and communicat-
ing information about assessments to other members of
the health team.
A. Methods of data collection
1. Physical examination: The use of inspection,
Fig 6.2 The helix of critical thinking schematically elon- auscultation, percussion, and palpation to collect
gated. (From Nugent and Vitale [2015]. Fundamentals success, data about a client’s physical status. (See “Tech-
4th ed. Philadelphia: F.A. Davis Company, with permission.) niques of Physical Assessment Used by Nurses,”
in Chapter 14, Physical Assessment.)
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Fig 6.3 The interactive nature of the helix of critical thinking within the nursing process. (From
Nugent and Vitale [2015]. Fundamentals success, 4th ed. Philadelphia: F. A. Davis Company, with permission.)
shoulder, the nurse makes an inference that diagnostic label. For example, Related to
the client is experiencing pain. To validate this physical immobilization. The list of related
conclusion, the nurse asks, “I noticed that you factors in the taxonomy is not all-inclusive
are rubbing your shoulder. Is it causing you because it is impossible to list all possible
discomfort?” factors.
b. If a client says, “I feel as though my bladder will
burst,” the nurse makes the inference that the
DID YOU KNOW?
Although nursing diagnoses provide a framework
client might be experiencing urinary retention.
for identifying a client’s nursing problems using a
To validate this, the nurse should palpate the
standardized nomenclature or language, some
client’s abdomen for distention. The nurse
professionals believe that they have become too
also can ask questions that clarify the client’s
complex and abstract to be useful in everyday
statement.
practice. As a result, some areas of practice are
5. Nurses should ask the following questions after
moving away from using nursing diagnoses.
arriving at conclusions.
a. “Did I miss anything?” D. Communicating client nursing diagnoses, problems,
b. “What else do I need to know?” or needs
c. “Has the client’s condition or situation changed 1. Nurses communicate client nursing diagnoses,
since I initially assessed the client?” problems, or needs in a written plan of care.
d. “Are there any inconsistent or conflicting data
that require clarification?”
e. “Is my data cluster complete, or do I need to
collect additional data to better support my MAKING THE CONNECTION
conclusion?” NANDA Taxonomy and a Nursing Diagnosis
C. Identifying nursing diagnoses A nurse is caring for a newly admitted client who has
1. Introduction to nursing diagnoses. paralysis of the legs as a result of a spinal cord injury
a. Nursing diagnoses are statements of specific several years ago. The client sits in a wheelchair most
health problems that nurses are legally allowed of the day and lies in the supine position when sleep-
to independently identify, prevent, and treat. ing. The nurse identifies that the client has a shallow,
b. They convert an initial conclusion into a diag- round, partial-thickness loss of dermis over the sacrum.
nostic statement. The wound bed is red with no evidence of sloughing.
c. They logically link the assessment step to the The nurse identifies the nursing diagnosis: Impaired
planning, implementation, and evaluation skin integrity (diagnostic label) related to physical
steps of the nursing process. immobilization (related to factor). Because the nurse
d. NANDA International provides a taxonomy understands that there can be more than one “related
of diagnostic labels and etiologies. to” factor, the nurse includes all the causes of the
e. Each nursing diagnosis in the taxonomy follows client’s impaired skin and develops this nursing diag-
the same organization for the presentation of nosis: Impaired skin integrity related to physical immo-
information. bilization, altered sensation, and pressure. The nurse
(1) Diagnostic label (title or name): A word or expands the nursing diagnosis to include “secondary
phrase that is based on a pattern of inter- to” information to make the etiology clearer. Often,
connected data. For example, Impaired “secondary to” information is a pathophysiological
skin integrity. process or medical diagnosis. The nursing diagnosis
(2) Definition: Explains the meaning of the is now: Impaired skin integrity related to immobility,
diagnostic label, which differentiates it altered sensation, and pressure secondary to motor
from similar nursing diagnoses. For exam- deficits.
ple, Altered epidermis and/or dermis. The nurse further expands the nursing diagnosis to
(3) Defining characteristics: Identifies clinical include “evidenced by” information to make the etiology
indicators (signs and symptoms) that even more clear. Often, “evidenced by” information is
support the diagnostic label. For example, the clinical indicators (signs and symptoms) included in
Invasion of body structures, destruction the defining characteristics in the NANDA taxonomy. The
of skin layers (dermis), disruption of skin final nursing diagnosis is: Impaired skin integrity related
surface (epidermis). to inactivity, altered sensation, and pressure secondary
(4) “Related to” factors: Situations, events, to motor deficits as evidenced by the inability to inde-
or conditions that precede, cause, affect, pendently move the legs.
or are in some way associated with the
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2. The plan of care may be kept in a variety of (4) A low-priority problem should pose the
places (e.g., client’s clinical record, the medication least threat and be ranked last. It may
administration record, and interdisciplinary require minimal support (e.g., nausea).
clinical pathways). c. Client’s priorities.
(1) Ranks client needs based on what is most
V. Planning important to the client.
(2) Although a client’s preference should
Planning, the third step of the nursing process, provides always be taken into consideration, basic
direction for nursing interventions. It is concerned with life-threatening needs require urgent
identifying priorities, establishing goals and expected out- interventions and override less important
comes, and selecting nursing interventions that will help needs.
the client achieve those goals and expected outcomes. d. Future impact of the client’s condition.
Planning begins when a client is admitted and is ongoing (1) Although a problem might not be life
to meet the changing or emerging needs of the client. threatening and is not recognized by the
Effective planning includes collaboration with all appro- client as important, the nurse may deter-
priate health team members to facilitate continuity of mine that it can cause future negative
care in a client-centered, individualized, and coordinated consequences if not addressed.
manner. Planning culminates in a document about the (2) For example, a nurse identifies that a client
proposed plan of care that is communicated to all mem- newly diagnosed with type 1 diabetes has
bers of the health team. dirty feet and is wearing sandals instead
A. Identifying priorities of shoes that enclose the feet. The nurse
1. A priority is something ranked highest in terms knows that people with diabetes are at risk
of importance or urgency. for foot problems secondary to impaired
2. A nurse must place a client’s nursing diagnoses, circulation to the lower extremities. There-
problems, and needs in order of importance when fore, the client has a potential for skin
confronted with a variety of client issues. breakdown, which can lead to infection
3. A nurse must have a strong foundation of scien- and even amputation. The nurse ranks this
tific theory, knowledge of the commonalities issue as a priority and plans interventions
and differences in response to nursing interven- to educate the client about foot care.
tions, and theories to determine the priority of B. Identifying goals and expected outcomes
a client’s needs. 1. Basic concepts.
4. Factors that promote the prioritization of care. a. A goal is a broad statement about the status one
a. Maslow’s hierarchy of needs. expects a client to achieve.
(1) Needs are placed in order from the b. A goal generally is derived from the “diagnostic
most basic needs to the highest-level label” component of a nursing diagnosis. For
needs. example, if a client has the nursing diagnosis
(2) Physiological is the first-level need, fol- Ineffective airway clearance related to excessive
lowed by safety and security, love and be- respiratory secretions, the goal might be: “The
longing, self-esteem, and self-actualization client will maintain a patent airway.”
(see Fig. 7.3 in Chapter 7, Evidenced-Based c. An outcome identifies a specific change in a
Practice). client’s condition as a result of nursing inter-
b. Urgency of the health problem. ventions. It is commonly influenced by the
(1) Ranks problems based on the degree of “related to” component of a nursing diagnosis.
threat to the client’s life. The nurse can Also, it provides criteria to be used in the evalu-
use the ABCs of assessment (Airway, ation phase of the nursing process. For exam-
Breathing, Circulation) when determin- ple, the outcome statement using the previously
ing priorities. stated goal (“The client will maintain a patent
(2) A high-priority problem poses the greatest airway”) might be: “The client will expectorate
threat and should be addressed first (e.g., respiratory secretions while hospitalized” (see
an impaired airway). Box 6.1, Nursing Outcomes Classification
(3) A medium-priority problem follows a [NOC] System).
high-priority problem. It may be related d. Clients and nurses together should set goals and
to harmful physiological responses that outcomes to ensure that these goals and out-
are not an immediate threat to life (e.g., comes are realistic, achievable, and in alignment
impaired mobility). with what the client and nurse want to achieve.
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Box 6.2 Nursing Interventions Classification (NIC) 3. A plan of care may require modification after
System the evaluation step of the nursing process when
it is identified that the client did not achieve an
The Nursing Interventions Classification (NIC) system is expected outcome or because the client’s status
a standardized classification of nursing interventions. It improved.
includes both physiological and psychosocial interventions
that can be performed across all nursing disciplines. It con-
sists of intervention labels. Each intervention label has a VI. Implementation
definition and a list of related nursing actions. The advan-
tages of the NIC system are that it uses language common Implementation, the fourth step of the nursing process,
to all health-care professionals, it is specific, and it is based is the actual performance of nursing actions. It is the
on evidence-based practice. execution of the plan of care and involves thinking and
Example of NIC interventions for pressure ulcer care:
• Pressure ulcer care: Monitor color, temperature, edema, doing. Therefore, nurses must have not only a strong
moisture, and appearance of surrounding skin; note charac- knowledge base of the sciences, nursing theory, nursing
teristics of any drainage. practice, and legal parameters of nursing interventions
but also the psychomotor skills to implement procedures
safely. Nurses must implement only nursing actions that
are described in their state’s nurse practice act and con-
D. Communicating the plan of care form to professional nursing standards of care.
1. Plans of care promote communication and coordi- A. Legal parameters of nursing interventions
nation among health team members, improving 1. A nurse must know the legal parameters of
the continuity of client care. nursing interventions, which include:
2. Information that should be included on a compre- a. Dependent nursing interventions.
hensive plan of care includes: (1) Require a prescription from a primary
a. Client nursing diagnoses, problems, or needs health-care professional with prescriptive
and related independent and dependent privileges (e.g., physicians, podiatrists,
nursing interventions. dentists, physician’s assistants, nurse
b. Activities of daily living (ADLs) and basic needs. practitioners).
c. Medical prescriptions and the nursing (2) Nurses must ensure that prescribed inter-
interventions required to implement them. ventions and medications are appropriate
d. Requirements to prepare the client for to meet the needs of a client. If a nurse
discharge, such as teaching, equipment, implements an inappropriate intervention
and services. or prescription, the nurse can be held
3. Various types of care plans are used. legally accountable as a contributor to the
a. Computer-generated care plans can be stan- initial error made by the primary health-
dardized or individualized. The nurse chooses care provider. Nurses must question
a nursing diagnosis or health problem, and the inappropriate prescribed interventions
computer presents potential goals/outcomes or prescriptions and not follow them
and nursing interventions. The nurse can then blindly.
select interventions that are appropriate for the (3) Examples of dependent nursing interven-
client. The computer then generates a written tions include:
printout of the plan of care. (a) Administering medications or
b. Multidisciplinary care plans (collaborative intravenous solutions.
care plans, critical or clinical pathways) (b) Implementing activity prescriptions.
sequence care that is to be delivered each (c) Inserting or removing a urinary
day during a client’s length of stay. Each day retention catheter.
has a column and vertical boxes that address (d) Providing a diet.
specific care that is to be delivered by each (e) Implementing wound or bladder
health-care discipline. irrigations.
E. Modifying the plan of care b. Independent nursing interventions.
1. Plans of care are dynamic and require modifica- (1) Registered nurses can legally plan and
tion to keep them current and relevant. implement independent nursing interven-
2. The original plan of care may require changes tions without supervision or direction from
because the original plan was inadequate or a person with a prescriptive license.
inappropriate or because additional assessments (2) Each state’s nurse practice act defines the
provide new information. scope of nursing practice within the state.
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b. The nurse should know the steps, principles, delegated care, is knowledgeable, and is
rationales, and expected outcomes relative to able to deliver the care safely.
nursing procedures to implement them in the (3) Ensuring that the care is implemented
appropriate situation safely. according to standards of care.
c. Examples include administering medications (4) Evaluating the client’s responses to the
via various routes, suctioning a client’s respira- interventions implemented.
tory tract, changing a wound dressing, and (5) For additional information about delegation
irrigating a colostomy. see “Delegation” in Chapter 5, Leadership
6. Employing psychosociocultural interventions. and Management.
a. Nurses use therapeutic interviewing tech- 8. Reporting and documenting nursing interventions
niques to encourage clients to express feelings and client responses.
and concerns. Once the nurse identifies a a. Nurses communicate information verbally and
client’s emotional needs, the nurse continues in writing to other members of the health team
to support the client emotionally while explor- to provide continuity of client care. Written
ing potential coping strategies. In addition, documentation also establishes a permanent
the nurse uses interpersonal interventions legal record of the care provided and the
when working as an advocate for the client, client’s response.
coordinating health-care activities, and collab- b. Examples include documenting vital signs
orating with others on the client’s behalf. on a client’s graphic record, indicating the
b. Examples include using nondirective interview- characteristics of a client’s skin integrity on
ing techniques, gently addressing a client’s a pressure ulcer flow sheet, providing a verbal
behavior, collaborating with a client to identify report regarding the status of clients to a nurse
a goal, and explaining to family members that arriving for the next shift, and documenting
their loved one’s angry behavior is associated the administration of medications and client
with the anger stage of grieving in response responses to medications.
to the diagnosis of cancer.
! c. If interventions are not documented, they are
7. Delegating, supervising, and evaluating delegated
considered not done.
nursing interventions.
a. Delegation is transferring the authority to act
to another while retaining accountability for VII. Evaluation
the outcome.
b. Nurses may delegate nursing care to: Evaluation, the fifth step of the nurse process, involves
(1) Unlicensed assistive nursing personnel. issues related to structure, process, and client outcomes.
(a) Uncomplicated, basic interventions. The nurse first reassess the client to identify client re-
(b) Examples: Bathing a bed-bound sponses to interventions (actual outcomes) and then
client, ambulating a stable postopera- compares the actual outcomes with the planned outcomes
tive client, obtaining vital signs from (expected outcomes) to determine goal achievement. It is
clients who are stable. a continuous process that requires the plan of care to be
(2) Licensed practical nurse (LPN). modified as often as necessary either during or after care.
(a) Routine nursing care for clients who are A. Components of evaluation
stable and whose care is uncomplicated. 1. Structure.
(b) Examples: Administering medications, a. Associated with the setting and effect of organi-
changing a sterile dressing, instilling zational features on the quality or excellence of
an enema. nursing care.
(3) Registered nurse. b. Based on such things as policy and procedures,
(a) Complex nursing interventions. economic resources, available equipment, and
(b) Examples: Performing a physical the number, credentials, and experiential back-
assessment, teaching a client how to ground of members of the nursing team.
self-administer insulin, formulating c. Example of a structure goal against which the
a client’s plan of care. delivery of nursing care can be assessed: A
c. The nurse delegating care is responsible for: controller pump is used for administration
(1) Assuming responsibility for the care that is of intravenous medication.
delegated and its consequences. 2. Process.
(2) Ensuring that the person implementing a. Associated with evaluation of clinical perfor-
the care is legally permitted to provide the mance of nursing team members.
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b. Example of a process goal against which the 2. Compare an actual outcome with an expected
care delivered by a nurse can be assessed: outcome to determine goal achievement.
The client’s privacy is maintained by pulling a. If they are the same, then the nurse can infer
the curtain and draping the client when assess- that the nursing care was effective in assisting the
ing a client’s wound. client to achieve the expected outcome. In other
3. Client outcome. words, a positive evaluation is indicated when an
a. Associated with measurable changes in a actual outcome meets the expected outcome.
client’s status as a result of care implemented b. If they are not the same, then the nurse can
by a nurse. infer that the nursing care was not effective
b. Example of an expected client outcome in assisting the client to achieve the expected
against which an actual client outcome can outcome. In other words, a negative evaluation
be assessed: The client’s skin will remain clean, is indicated when an actual outcome does not
dry, and intact. meet the expected outcome.
B. Types of evaluation activities c. Once it is determined that the expected out-
1. Routine evaluations. come was not achieved, the nurse must analyze
a. Occur at preset regular time frames. factors that may have affected the actual out-
b. For example, obtaining clients’ vital signs every comes of care.
shift; documenting intake and output every 3. Analyze factors that may have influenced
shift and every 24 hours. nonachievement of expected goals/outcomes.
2. Ongoing evaluations. a. Each step of the nursing process must be exam-
a. Occur during and immediately after administer- ined to determine what contributed to the failure
ing nursing care or after interacting with a client. to achieve expected goals/outcomes. For example,
b. For example, assessing a client’s response to the nurse must ask important questions such as:
irrigation of a colostomy; determining whether (1) Was the data cluster thorough and accurate?
a client understands the content in a teaching (2) Was the nursing diagnosis, problem, or
session. need identified correctly?
3. Intermittent evaluations. (3) Was the goal realistic and attainable?
a. Occur in specific situations. (4) Were the expected outcomes specific and
b. For example, obtaining daily weights to moni- measurable?
tor a client receiving a diuretic; assessing the (5) Did the planned interventions address all
degree of pain relief after a client receives an the etiological factors of the problem?
analgesic. (6) Were the nursing interventions consis-
4. Terminal evaluations. tently implemented as planned?
a. Occur in preparation for a client’s discharge; b. The specific reason for not achieving a goal/
health-care agencies generally have a compre- expected outcome should be identified. A
hensive discharge form that provides structure variety of reasons may have influenced the
and consistency within an agency. nonachievement of a goal/expected outcome.
b. For example, evaluating a client’s physical and For example, the client might not have shared
emotional status; determining progress toward important information, the staff might not have
goal/outcome achievement; and formulating completed all tasks as planned, the client might
a plan of care to be implemented in the com- not have been motivated to participate ade-
munity setting, including topics such as med- quately in the planned care, or the client’s
ications, treatments, diet, and scheduled condition may have changed.
follow-up care. D. Modifying the plan of care
C. Nursing interventions to ensure thorough evaluation 1. Plans of care are dynamic and require modification
of client responses to nursing care to keep them current and relevant.
1. Reassess the client to identify actual outcomes 2. The plan of care must be modified as soon as a
(client responses). nurse identifies that a plan of care is ineffective.
a. The nurse must reassess the client to collect 3. The plan will have to be modified when an ex-
data, organize the data, and determine the pected goal/outcome is met. Goals and expected
significance of the data. outcomes advance to address evolving needs as the
b. Actual outcomes are then compared to the client moves toward health on the health-illness
expected outcomes identified in the written continuum.
plan of care to determine whether the client 4. Once a new plan of care is implemented, the step
successfully achieved the goals/outcomes. of evaluation beings again.
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1.
2.
3.
4.
5.
6.
7.
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1.
2.
3.
4.
5.
6.
7.
C. Identify whether the client, wife, primary health-care provider, and nurse are primary, secondary, or tertiary sources of data.
1.
2.
3.
4.