THE CORNERSTONE OF NURSING PRACTICE

People use critical

thinking wherever they
want to use clear, focused
thinking to achieve a
result.
Nurse need to be critical
thinkers when working
with the patients to help
them cope with the
disease or illness,
Critical thinking is defined as:
a systematic way to form and shape
ones thinking. It functions
purposefully and exactingly. It is
thought that is disciplined,
comprehensive based on intellectual
standards and a result well reasoned.


It is guided by standards, policies and procedures, ethics, codes
and laws.
Based on principles of nursing process, problem solving and the
scientific method.
Carefully identifies the key problem, issues and risks involved in
the care of patient, families.
Is driven by patient, family and community needs as well as nurses
needs to give competent, efficient care
Calls for strategies that makes the most of the human potential and
compensate for problems caused by human nature.
Is constantly revaluating, self- correcting, striving to improve.

It is the evidence based descriptions of behaviours that
demonstrates the knowledge, characteristics and skills that
promote critical thinking in clinical practice.
Purpose of Thinking
Adequacy of Knowledge
Potential Problems
Helpful Resources
Critiques of Judgement/ Decision

The term nursing process and the framework it implies are relatively new.
In 1955, Hall originated the term (care, cure, core), 3 steps: note observation,
ministration, validation
Johnson (1959), Nursing seen as fostering the behavioral functioning of the
client.
Orlando (1961), identified 3 steps: clients behavior, nurses reaction, nurses
action. Nursing process set into motion by clients behavior
Weidenbach (1963) were among the first to use it to refer to a series of phases
describing the process.
Wiche (1967) Nursing is define as an interactive process between client and
nurse. 4 steps: Perception, Communication, Interpretation, Evaluation.
Yura and Walsh (1967) suggested the 4 components APIE.
Knowles (1967) described nursing process as: discover, delve, decide, do,
discriminate.


Published standards of nursing practice. Diagnosis distinguished as
separate step of nursing process (1973)

Published Nursing a Social Policy Statement. Diagnosis of actual
and potential health problems delineated as integral part of
nursing practice (1980)

Published Standard of Clinical Nursing Practice. Outcome
identification differentiated as a distinct step of the nursing
process. Therefore, the six steps of the nursing process are as
follows: A.D.OI.P.I.E. (1991).

It is a series of planned
actions or operations
directed towards a
particular result or goal.

It is a systematic,
rational method of
planning and providing
individualized nursing
care.


Is the underlying scheme that provides order and direction to
nursing care.
It is the essence of professional nursing practice.
It has been conceptualized as a systematic series of
independent nursing actions directed toward promoting an
optimum level of wellness for the client.
It is cyclical; the components follow a logical sequence, but
more than one component may be involved at any one time.

To identify a clients health status, actual or potential health
care problems or needs, to establish plans to meet the
identified needs, and to deliver specific nursing interventions to
meet those needs.

It helps nurses in arriving at decisions and in predicting and
evaluating consequences.

It was developed as a specific method for applying a scientific
approach or a problem solving approach to nursing practice.

Problem-Oriented
Goal Oriented
Universally Applicable
Open & Flexible
Cyclic & dynamic
Client Oriented & Individualized Approach
Interpersonal Collaboration
Systematic, Planned
Involves Creativity
Emphasis on Feedback
Ensures quality care
Systematic & scientific plan of care
Care provided is available in written form.
Avoids duplication & omissions.
Enhances communications as well as cooperation
Helps in meeting the patients individualized preferences & needs.
Participation of patient in care is encouraged
Used as a legal document.
Used as a learning tool for medical and nursing students
Provides an organized method of giving care
Helps nurses to gain satisfaction by getting results.
Promotes flexibility.
Helps improve continuity of care.

NURSING
PROCESS
ASSESSMENT
NURSING
DIAGNOSIS
OUTCOME
IDENTIFICATION
PLANNING
IMPLEMENTATION
EVALUATION
To establish baseline information on the client.
To determine the clients normal function.
To determine the clients risk for diagnosis function.
To determine presence or absence of diagnosis function.
To determine clients strengths.
To provide data for the diagnostic phase.


COLLECT DATA

VALIDATE DATA

ORGANIZE DATA

RECORDING DATA

Assessment involves reorganizing and collecting CUES:
Objective (overt) & Subjective (covert).

Initial Assessment
-Initial identification of normal function, functional status and
collection of data concerning actual and potential dysfunction.
Focus Assessment
-Status determine of a specific problem identified during previous
assessment.
Time Lapsed Reassessment
-Comparison of client current status to baseline obtained previously,
detection of changes in all functioning health problems after an
extended period of time .
Emergency Assessment
- Identification of life threatening situation.

Observation act of noticing client cues.
*looking, watching, examining, scrutinizing, surveying, scanning,
appraising.
*uses of different senses: vision, smell, hearing, touch.
Interviewing interaction and communication.
Physical Examination
INSPECTION
PERCUSSION
AUSCULTATION
INTUITION
- defined as insights, instincts or clinical experiences to make judgment about
client care.

TYPES OF DATA:
Subjective & Objective Data
CHARACTERISTICS OF DATA:
Purposeful
Complete
Factual & Accurate
Relevant
SOURCES OF DATA:
Patient
Family & Significant Others
Patient Records
Medical history, Physical Examination & Progress Notes
METHODS OF DATA COLLECTION:
Interview & Health History
Physical Examination
Diagnostic & Laboratory Data
INTERPRETATION OF ASSESSMENT DATA & MAKING NURSING
JUDGEMENT.
DATA VALIDATION
Comparison of the collected data with another source
ANALYSIS & INTERPRETATION
DATA CLUSTERING
DATA DOCUMENTATION
Preparatory Phase
(Pre-interaction)
Introductory Phase
(Orientation)
Maintenance Phase
(Working)
Concluding Phase
(Termination)


A process in which people affect one another through
exchange of information, ideas, and feelings.

Documentation/Recording is a vital aspect of nursing
practice.

Include both oral and written exchange of information
between caregivers.

Verbal Communication
- Uses spoken or written words.

Non-verbal Communication
- Uses gestures, facial expression, posture/gait, body
movements, physical appearance (also body language), eye
contact, tone of voice.



SIMPLICITY
- commonly understood words, brevity, and completeness
CLARITY
- exactly what is meant
TIMING and RELEVANCE
- appropriate time and consideration of clients interest and
concerns
ADAPTABILITY
- adjustment depending on moods and behavior
CREDIBILITY
- worthiness of belief

DOCUMENTATION
- Serves as a permanent record of client information and
care.
REPORTING
- takes place when two or more people share information
about client care
NURSING DOCUMENTATION: the charting of documents, the
professional surveillance of the patient, the nursing action
taken in the patients behalf, and the patients programs
with regards to illness.

1. Communication
2. Legal Documentation
3. Research
4. Statistics
5. Education
6. Audit and Quality Assurance
7. Planning Client Care
8. Reimbursement
A. Source Oriented Medical Record
traditional client record
FIVE BASIC COMPONENTS:
1. Admission sheet
2. Physicians order sheet
3. Medical history
4. Nurses notes
5. Special records and reports

B. Problem-oriented medical record (POMR)
- arranged according to the source of information.

FOUR BASIC COMPONENTS:
1. Database
2. Problem list
3. Initial list of orders or care plans
4. Progress notes:
Nurses notes
(SOAPIE)
Flow sheets
Discharge notes or referral summaries


1. BREVITY.
2. USE OF INK / PERMANENCE.
3. ACCURACY.
4. APPROPRIATENESS.
5. COMPLETENESS & CHRONOLOGY / ORGANIZATION /
SEQUENCE / TIMING.
6. USE OF STANDARD TERMINOLOGY.
7. SIGNED.
8. In case of ERROR.
9. CONFIDENTIALITY.
10. LEGAL AWARENESS.
11. LEGIBLE.
12. DO NOT use the word PATIENT or PT in the chart.
13. A HORIZONTAL LINE drawn to fill up a partial line.

1. CHANGE-OF-SHIFT REPORTS OR ENDORSEMENT.
-for continuity of care / health care needs.
2. TELEPHONE REPORTS.
-provide clear, accurate, & concise information
-includes: when, who made/was, whom, what info
given/received.
3. TELEPHONE ORDERS.
- RNs duty, must be signed w/in 24 hours.
4. TRANSFER REPORTS
- from one unit to another.


1. Chart Accurately
2. Chart Objectively
3. Chart Promptly
4. Make No Mention of an Incident Report in the Chart
5. Write Legibly and Use Only Standard Abbreviations

1. Write Neat and Legibly
2. Use Proper Spelling and
Grammar
3. Write with Blue or Black
Ink and Use Military time
4. Use Authorized
Abbreviations
5. Transcribe Orders
Carefully
6. Document Complete
Information About
Medication
7. Chart Promptly

8. Never Chart Nursing Care
or Observation Ahead of
Time.
9. Clearly Identify Care
Given by Another Member
of the Health Care Team.
10. Dont Leave Any Blank
Spaces on Chart Forms.
11. Correctly Identify Late
Entries.
12. Correct Mistaken Entries
Properly.
13. Dont Sound Tentative
Say What You Mean

1. Dont Tamper with Medical Records.
2. Dont criticize other Health Care Professionals in the chart.
3. Dont Document any Comments that a patient or family
member makes about a potential lawsuit against a health
care professional or the hospital.
4. Eliminate bias from written descriptions of the patient.
5. Precisely document any information you report to the doctor.
6. Document any potentially contributing patient acts.

The word Diagnosis is derived from the words meaning to
distinguish or to know.
According to North American Nursing Diagnostic Association
(NANDA) 1992 defines nursing diagnosis as following:
A clinical judgement about individual family or community,
responses to actual and potential health or life process. Nursing
diagnosis provides the basis for collection of nursing interventions
to achieve outcomes for which the nurse is accountable
A nursing diagnosis is a clinical judgement about individual, family
or community responses to actual and potential health problems
for life process
Basis for nursing interventions to achieve outcomes for which
the nurse is accountable
Focuses on actual or potential response to a health problem
Leads to development of an individualized plan of care.
Helps to analyze collected data.
Helps to identify the clients strengths and weakness
Helps to identify the client normal functional level
statement.
NANDA DIAGNOSIS is a list of diagnostics made by the NORTH
AMERICAN NURSES DIAGNOSTIC ASSOCIATION.
The diagnosis provides a common language which facilitates
communication among nurses.

Provides a precise definition that gives a member of the
health care team a common language for understanding the
patients needs
Distinguishes the nurses role from that of the physician or
other health care professionals.
Helps nurses focus on the scope of nursing practice.
NANDA , Internationally identifies 4 types of nursing
diagnosis:
Actual Diagnosis
High-Risk Diagnosis
Wellness Nursing Diagnosis
Syndrome Diagnosis
Diagnostic label
Related factor
Definition
Risk factor
Support of the diagnostic statement
One-Part Statement Diagnosis
Two-Part Statement Diagnosis
Three-Part Statement Diagnosis
Errors can occur in the diagnostic data during
Data Collection
Data Interpretation
Data Clustering
Diagnostic Statement
Provides direction for the planning process and selection of the
nursing interventions
Helps in communicating the client centered problems to other
professionals
Ensures quality nursing care
Develops Specific nursing interventions for each client
Coding of nursing care plans in computer helps for direct access.
Helps to assess the nurses role in health care
It helps the clinical, educational, research, legislation and nursing
as a profession.
Helps to bridge the gap between knowledge & practice.
It is a purposeful activity which involves critical thinking
It is the determination of what is to be done, when it is to
be done, where it is to be done and who will do and
also how to evaluate the results.
DEFINITION:
According to Kozier: Planning is a deliberate
systematic phase of the nursing process that involves
decision making and problem solving.
According to Kypt: Planning is defined as the
selecting and carrying out of series of action assigned
to achieve stated goals.

Direct client care activities
Promote continuity of care
Focus charting requirements
Allow for delegation of specific activities
TYPES:
Initial Planning
Ongoing Planning
Discharge Planning
PLANNING
Setting
Priorities
Determining
the Goals or
Expected
Outcomes
Selecting
the Nursing
Strategies
Developing
the Nursing
Care Plan
High Priority
Intermediate Priority
Low Priority

Evaluates the clients progress towards desired outcomes
Evaluates the effectiveness of selected nursing interventions.

TYPES:
SHORT TERM GOALS
LONG TERM GOALS
EXPECTED OUTCOMES:
It is specific measureable change in a patients status that the
nurse expects to occur in response to the nursing care
Derived primarily from the first clause of the nursing
diagnosis.
Possible to achieve.
Stated in terms of client responses rather than nursing
activities.
Statement of one specific client behavior.
Specific & Concrete.
Appraisable & Measurable.
Valued by the client & family.
Compatible with therapies of other professionals.
A Nursing Intervention is any direct care treatment that
a nurse performs on behalf of the client, whether nurse
initiated or physician initiated.
TYPES OF NURSING INTERVENTIONS:
Independent interventions
Dependent interventions
Collaborative interventions
Safe &appropriate for the individuals age, health.
Achievable with the resources available
Congruent with the clients values &beliefs
Congruent with other therapies
Based on nursing knowledge and experience or knowledge
from relevant sciences
Within established standards of care as determined by state
laws, professional associations and the policies of the
institution.
Nursing orders are instructive for the specific
activities the nurse performs to help the client to
meet the established health care goals.
A complete well written nursing order is composed of 5
components:
Date:
Specific action verb
Content area
Time element
Signature
The nursing care plan is a written guide that organizes
information about a clients care into a meaningful
whole. It includes the actions nurses must take to
address the clients nursing diagnosis and meet the
stated goals.

To provide direction for individualized care of the client
To provide for continuity of care
To provide direction about what needs to be documented on the
clients progress notes.
To serve as a guide for assigning staff to care for the client.
To serve as a guide for reimbursement from ,medical insurance
companies often called third party reimbursement.
To provide for individual and family participation in the nursing
care plan.
To outline a program for health education of individuals and
significant others.
To encourage adequate discharge planning.
To provide a source of information for quality improvement and
research.
Criteria
The plan must be developed by an registered nurse
It must be documented in the clients health record
It must reflect the standards of care established by the institution
and the profession.
The plan of care is nursing centered.
The plan of care is a step by step process.


Sufficient data are collected to substantiate nursing
diagnosis.
At least one goal must be stated for each nursing diagnosis
Outcome criteria must be identified for each goal
Nursing interventions must be specifically developed to meet
the identified goal
Each intervention should be supported by a scientific
rationale.
Evaluation must address whether each goal was completely
met, partially met or not met.
Date & sign the plan
Use the category headings
Nursing Diagnosis
Goals/Outcome Criteria
Nursing orders
Evaluation and include a date for the evaluation of each goal.
Use standardized medial or English symbols and key words rather
than complete sentences to communicate your ideas.
Refer to procedure books or other sources of information rather
than including all the steps on a written plan.
Tailor the plan to the unique characteristics of the client by
ensuring that the clients choices are included. This reinforces the
clients individuality and sense of control.
Ensuring that the nursing plan incorporates preventive and
health maintenance aspects as well as restorative.
Ensure that the plan contains orders for ongoing assessment
of the client.
Include collaborative and coordination activities in the plan.
Include plans for the clients discharge and home care needs.
Student Nursing Care Plans
Individually Developed Nursing Care Plans
Standardized Nursing Care Plans
Teaching Plans
Practice Guidelines
Case Management Care Plans
Computerized Plans
Implementation refers to the action phase of the nursing
process in which nursing care is provided. It is the actual
initiation of the plan and recording of nursing actions.
Bulechek define nursing interventions as any direct
treatment that a nurse performs on behalf of a client.
These treatments include nurse- initiated treatments
resulting from nursing diagnoses and performance of the
daily essential functions for the client who cannot do these.
Intellectual/ Cognitive Skills
Interpersonal/ Affective Skills
Technical/ Conative Skills
Implementation
Recording
Nursing Actions
Reassessing
Setting
priorities
Performing
Nursing
Intervention
Cognitive Interventions
Educational Interventions
Supervisory Interventions
Interpersonal Interventions
Coordinating Interventions
Supportive Interventions
Psychosocial Interventions
Technical Interventions
Maintenance Interventions
Surveillance Interventions
Psychomotor Interventions
Review of planned interventions for appropriateness.
Scheduling & organizing the interventions
Collaborating with other team members
Supervising & delegating nursing care by other members of the
nursing team.
Achievement of the organizational & client care goals.
Providing direct nursing care.
Providing counselling
Involving the client in health care
Teaching the client & family
Making referrals to other health care professionals.
Documenting nursing care provided.

To evaluate is TO JUDGE or TO APPRAISE.
Evaluation is a planned, ongoing, purposeful activity in
which client and health care professionals determine:
1. The clients progress towards goals achievement
2. The effectiveness of nursing care plan.

Evaluation is defined as the judgement of the
effectiveness of nursing care to meet client goals based on
the clients behavioural responses.
To collect the objective & subjective data to make judgements
about nursing care developed.
To examine the clients behavioural responses to nursing
interventions.
To compare the clients behavioural responses with predetermined
outcome criteria
To appraise the extent to which client goals were attained or
problems resolved.
To appraise involvement and collaboration of the client, family
members, nurses and health care team members in health care
decisions
To provide a basis for the revision of the nursing plan of the care
evaluation
To monitor the quality of nursing care and its effect on the clients
health status.
Structure Evaluation
Process Evaluation
Outcome Evaluation
Ongoing Evaluation
Intermittent Evaluation
Terminal Evaluation
Review client goals and Outcome Criteria
Collect Data
Measure Goal/ Outcome Criteria
Assess the facilitators of Goal Attainment
Assess the barriers to Goal Attainment
Record Judgement or Measurement of Goal Attainment.
Revise or Modify the Nursing Care Plan.
The nursing process is the best way to provide best nursing
care to the patients. Adoption of nursing process enable
nurses to provide systematically planned nursing care and
interventions and the nursing process also safeguards the
nurse and her patients life from medical legalities.