Vous êtes sur la page 1sur 15

6069_Ch06_133-160 14/03/17 5:42 pm Page 135

Chapter 6

Critical Thinking and

the Nursing Process

Collaboration Patient-Centered Care

Communication Professionalism
Evidenced-Based Practice


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

6069_Ch06_133-160 14/03/17 5:42 pm Page 136

136 Unit 2 Essential Nursing Care Concepts

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.)
6069_Ch06_133-160 14/03/17 5:42 pm Page 137

Chapter 6 Critical Thinking and the Nursing Process 137

b. Reflect on your learning. Examine your per-

formance: engage in post conferences, main-
tain a journal that objectively and subjectively
explores your experience, ask faculty members
to provide feedback on your progress and
to make suggestions for improving critical
thinking abilities.
c. Participate in a study group to dissect and
examine information, work on case studies,
and answer test questions and then identify
rationales for right and wrong answers.

II. Introduction to the Nursing Process

The nursing process is a critical thinking framework that
involves assessing and analyzing human responses to plan
and implement nursing care that meets client needs as
evidenced by evaluation of client outcomes. Nurses use
critical thinking throughout the nursing process, which
involves both “thinking” and “doing,” to meet complex
client needs.
A. Components of the nursing process
1. Assessment.
2. Planning.
3. Analysis.
4. Implementation.
5. Evaluation.
B. Characteristics of the nursing process
1. Is client-centered.
2. Is interpersonal.
3. Is collaborative.
4. Is dynamic and cyclical.
5. Requires critical thinking.

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.)
6069_Ch06_133-160 14/03/17 5:42 pm Page 138

138 Unit 2 Essential Nursing Care Concepts

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.)

2. Interviewing. b. Gathers information about results of laboratory

a. Formal approach. examinations, diagnostic procedures, consulta-
(1) Used when collecting information in an tions by other members of the health team, and
arranged or official way, such as for a progress notes.
history and physical. B. Sources of data
(2) Usually involves direct rather than 1. Primary source.
open-ended questions. a. The client is the only primary source of data.
b. Informal approach. The data include information such as feelings,
(1) Used when collecting data in a casual physical and emotional perceptions, and beliefs.
and more relaxed manner, such as when
! b. The client is the most valuable source because the
exploring a client’s feelings while providing
data collected are most recent, unique, and specific
other nursing care.
to the client.
(2) Usually involves open-ended questions.
c. See also “Communication,” “Therapeutic 2. Secondary sources.
and Nontherapeutic Communication,” and a. These sources provide supplementary informa-
“Nursing Care Related to Communication” tion about the client from some place other
in Chapter 2, Communication, Collaboration, than the client but within the client’s frame
and Documentation. of reference.
3. Clinical record review. b. They include people other than the client (e.g.,
a. Involves monitoring information collected family members, friends, other health team
about the client in the clinical record. members).
6069_Ch06_133-160 14/03/17 5:42 pm Page 139

Chapter 6 Critical Thinking and the Nursing Process 139

senses, such as sight, touch, smell, and hearing,

and compared to an accepted standard.
Application of Critical Thinking b. Examples include body temperature, pulse and
to the Nursing Process respiratory rates, blood pressure, vomiting,
Critical thinking is a cognitive strategy by which one distended abdomen, presence of edema, lung
reflects on and analyzes personal thoughts, actions, and sounds, crying, skin color, and presence of
decisions. It involves purposeful, goal-directed thinking diaphoresis.
(e.g., the nursing process); requires judgment based on facts 2. Subjective data.
and principles of science rather than conjecture or trial a. Subjective data (also known as symptoms) are
and error (e.g., evidence-based practice); and requires covert information, such as feelings, percep-
numerous cognitive and personal competencies. The helix tions, thoughts, sensations, or concerns that
of critical thinking (Fig. 6.1) demonstrates the interwoven are shared by the client and can be verified
relationship between cognitive competencies and per- only by the client.
sonal competencies essential to thinking critically. b. Examples include pruritus, nausea, pain,
Throughout the thinking process, there is constant inter- numbness, attitudes, beliefs, values, and
action among cognitive competencies, among personal perceptions of the health problem and life
competencies, and between cognitive and personal circumstances.
competencies. The more cognitive competencies and per- 3. Verbal data.
sonal competencies a person possesses, the greater the a. Verbal data are spoken or written messages.
potential the person has to think critically (Fig. 6.2). Critical b. Requires the nurse to listen to the pace of the
thinking has an interactive relationship with the nursing communication pattern, tone of voice, vocabu-
process. The nursing process is a dynamic, cyclical process lary used, and presence of aggression, anxiety,
in which each phase interacts with and is influenced by or assertiveness.
the other phases of the process. Critical thinking is an c. Allows for the assessment of difficulties such as
essential component within, between, and among the slurring, lack of clarity, flight of ideas, difficulty
phases of the nursing process. Different combinations of finding the desired word, and inability to iden-
cognitive and personal competencies may be used during tify an item.
the different phases of the nursing process (Fig. 6.3). d. Examples include statements made by the client
or by a secondary source.
4. Nonverbal data.
c. A client’s clinical record is also a secondary a. Nonverbal data are observable behavior trans-
source, as it contains a vast amount of informa- mitting a message without words.
tion about the client’s physical, psychosocial, b. Examples include client’s appearance; facial
and economic history as well as information expression; body language, such as posture,
about the client’s progress regarding physical gestures, and eye contact or lack of eye contact.
and emotional responses to a health problem. D. Verifying collected data
1. Data must be double-checked (verified) after they
DID YOU KNOW? are collected.
Although a client’s clinical record is a secondary 2. Ensures validity and accuracy.
source, laboratory and diagnostic procedure results 3. Ensures that the nurse does not come to a con-
are direct objective measurements of the client’s clusion without adequate data to support the
status and are considered by some to be a primary conclusion.
source. The clinical record is a historical view of the 4. Involves collecting additional information to
client and, for that reason, is less current than data support the initial data.
collected from the client. a. If a client’s pulse is increased above the expected
3. Tertiary sources. range, the nurse should take the pulse again; if
a. These sources produce data from outside the it is still increased, the nurse should collect
client’s frame of reference. other vital signs to supplement the original
b. Examples include information from textbooks, information.
surveys, medical and nursing journals, drug b. If a client says, “I feel that I am in a big, black
books, and policy and procedure manuals. hole,” the nurse might use the communication
C. Types of data technique of clarification to have the client
1. Objective data. explain in more detail what was meant: “Tell
a. Objective data (also known as signs), are overt, me more about this big, black hole that you
measurable assessments collected via the feel you are in.”
6069_Ch06_133-160 14/03/17 5:42 pm Page 140

140 Unit 2 Essential Nursing Care Concepts

E. Communicating collected data on palpation of the suprapubic area; these clinical

1. Outcomes of nursing assessments must be docu- indicators all relate to urinary elimination and
mented on correct forms and in appropriate lead to the interpretation that the client may
places in the client’s clinical record. Many forms have urinary retention.
are used to document data and are organized by 5. Difficult-to-cluster information may at first
topic or body systems. seem unrelated because a variety of body systems
2. Communicating data ensures that pertinent and are involved. For example, a client has a weak,
current information relative to the client is shared thready pulse; decreased blood pressure; rapid res-
with other members of the health team. pirations; pallor; and clammy skin; these clinical
indicators cross body systems, but all are related
! 3. Data must be communicated in an objective and
to hypovolemic shock.
factual way and not be a summary of the nurse’s
6. Inductive reasoning moves from the specific to
interpretation of the data.
the general. For example, if you identify that a
4. Value words, such as good, bad, adequate, poor, client has a temperature and a wound with puru-
and tolerated well, should be avoided. For exam- lent drainage, you may come to the conclusion
ple, rather than saying that a client’s appetite is that the wound is infected.
poor, the nurse should document that the client 7. Deductive reasoning moves from the general to
ate half of a scrambled egg and a slice of toast. This the specific. For example, if you know that a newly
manner of documentation communicates objec- admitted client has a wound infection, you might
tive, measurable information about the client’s deduce that the client will have a temperature,
appetite. purulent drainage, and a culture and sensitivity
5. Value words related to a client’s behavior, such as laboratory result identifying the causative agent.
lazy, difficult, stubborn, rude, uncooperative, and 8. Data must be clustered before it can be interpreted.
foolish, should be avoided. These words reflect a 9. Established frameworks are available to provide
value judgment made by the nurse that may be structure for organizing clustered data.
influenced by bias and personal values or beliefs. a. Abraham Maslow’s hierarchy of human needs.
Nurses must always be nonjudgmental. b. Marjory Gordon’s functional health patterns.
6. Subjective data should be documented in the exact c. NANDA International (formerly the North
words expressed by the client and put in quotation American Nursing Diagnosis Association)
marks; this practice ensures that a client’s meaning nursing diagnosis taxonomy.
is not misinterpreted or inaccurately altered by 10. Most health-care agencies have their own
words used by the nurse to describe an event. admission assessment forms, which commonly
follow a systems approach to collecting and
IV. Analysis clustering data.
B. Interpreting data
Analysis, the second step of the nursing process, requires 1. Interpreting data requires identifying the signifi-
the nurse to use critical thinking strategies to scrutinize cance of clustered data.
data. Activities associated with this step include clustering 2. Determining significance requires a comparison of
data, interpreting data, and identifying and communicat- data collected with a wide range of standards and
ing a client’s nursing diagnoses, problems, or needs. norms (e.g., expected vital signs and laboratory
A. Clustering data values, growth and development patterns and
1. Involves grouping information into related cate- milestones, and cause-and-effect relationships).
gories, a beginning effort to organize and manage The nurse must then come to a conclusion about
information. a specific identified pattern. It also involves query-
2. Data can be clustered into general categories, ing evidence, exploring alternatives, and drawing
such as physiological, sociocultural, psychological, initial conclusions.
and spiritual. Then each category may be further 3. Conclusions are drawn after the significance of
reduced into specific categories, such as nutrition, data is determined. Conclusions are the opinions,
mobility, elimination, and oxygenation. perceptions, judgments, and inferences that result
3. Data can be easy or difficult to cluster depending from the interpretation of data.
on the amount and variety of data collected. 4. More data may be necessary to support an initial
4. Easy-to-cluster information commonly involves conclusion, thereby increasing validity and
only one body system. For example, a client reliability.
reports feeling low abdominal pressure, has not a. When a client has an increased blood pressure,
voided in 8 hours, and has abdominal distention pulse, and respiratory rate and is rubbing a
6069_Ch06_133-160 14/03/17 5:42 pm Page 141

Chapter 6 Critical Thinking and the Nursing Process 141

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
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
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
6069_Ch06_133-160 14/03/17 5:42 pm Page 142

142 Unit 2 Essential Nursing Care Concepts

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.
6069_Ch06_133-160 14/03/17 5:42 pm Page 143

Chapter 6 Critical Thinking and the Nursing Process 143

Box 6.1 Nursing Outcomes Classification (NOC) e. Be realistic.

System (1) The performance criteria identified must
be reasonable and feasible in light of the
The Nursing Outcomes Classification (NOC) system is a client’s emotional and physical status.
standardized classification of client outcomes that respond (2) Goals are realistic when the outcomes can
to nursing interventions. Each NOC outcome has a label, be achieved in the indicated time frames.
indicators, and measurement scale. The advantages of the
NOC system are that it uses language common to all health- (3) Example of a realistic outcome for a client
care professionals, it is specific, and it identifies indicators who had abdominal surgery is: “The client
with a measurement scale to allow nurses to evaluate client will exhibit bowel sounds within 3 days
progress toward an outcome. after surgery.”
Example of NOC outcomes with indicators for Impaired (4) Example of an unrealistic outcome for a
skin integrity:
• Tissue integrity: Skin and mucous membranes will be intact client with hemiplegia due to a brain
as evidenced by the following indicators: Skin intactness/ attack is: “The client will perform active
skin lesions/tissue perfusion/skin temperature. range-of-motion exercises independently
• Rate each indicator of tissue integrity: skin and mucous within 1 week.”
membranes: 1 = severely compromised, 2 = substantially C. Identifying nursing interventions
compromised, 3 = moderately compromised, 4 = mildly
compromised, 5 = not compromised. 1. Selecting appropriate interventions depends
on the accuracy and thoroughness of the data
2. Nursing interventions generally address the
2. Criteria for goals and outcomes. “related to” part (etiology) of the client’s problem
a. Be client centered. or nursing diagnosis. For example, if a person is
(1) The client is the center of the health team; at risk for impaired skin integrity related to urinary
therefore, the client should be the subject incontinence and immobility, the nursing interven-
of all goals and outcomes. tions selected should keep the client clean and dry
(2) For example, “The client will transfer from and relieve pressure.
the bed to a chair safely within 1 week.” 3. Nursing interventions should include nursing
Some agencies believe that the words the assessments, nursing care to avoid complications,
client are understood and therefore do not administration of prescribed treatments and
include them when stating a goal. medications, and health promotion and illness
b. Contain an action verb. prevention activities, as appropriate.
(1) The goal or outcome should identify the 4. Selected actions should have the greatest proba-
action that the client will learn, do, or bility of achieving the desired goal/outcome
express or the physical status the client with the least risk to the client. The nurse must
will attain. consider:
(2) For example, “The client will transfer from a. Cause: Planned action.
the bed to chair safely within 1 week.” b. Effect: Client’s response.
c. Include performance criteria. c. Risk: Potential for the client to have a nega-
(1) Actions must be specific and measurable. tive consequence as a result of the planned
For example, “The client will transfer from action.
the bed to chair safely within 1 week.” d. Probability: Degree to which the client may
(2) Conditions may be included to describe the have a positive consequence as a result of the
kind of assistance or resources needed by planned action.
the client. For example, “The client will e. Value of the consequences: Significance of
transfer from the bed to chair safely with a results of the planned action to the client.
one-person assist within 1 week.” 5. Selected interventions should be based on
d. Include a time frame. evidence-based practice—that is, interventions
(1) The goal must be achievable within a set that have been proven to be effective based
time frame. on rigorous scientific evidence and clinical
(2) For example, “The client will transfer from effectiveness studies rather than on tradition,
the bed to chair safely within 1 week.” intuition, or anecdotal information. Nursing
Additional examples of time frames include practice based on evidence improves the quality
by discharge, within 24 hours, at all times, of client care and justifies nursing interventions
and will maintain (the word maintain (see Box 6.2, Nursing Interventions Classifica-
implies continuously). tion [NIC] System).
6069_Ch06_133-160 14/03/17 5:42 pm Page 144

144 Unit 2 Essential Nursing Care Concepts

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.
6069_Ch06_133-160 14/03/17 5:42 pm Page 145

Chapter 6 Critical Thinking and the Nursing Process 145

(3) Examples of independent nursing interven- 2. Teaching.

tions include: a. Nurses provide teaching in relation to the
(a) Assessing a client. cognitive, psychomotor, and affective
(b) Diagnosing a client’s nursing needs. domains.
(c) Planning, implementing, and evaluating b. Examples include conducting a class about the
nursing care. signs and symptoms of hyperglycemia (cogni-
(d) Assisting with ADLs. tive domain), teaching a client how to self-
(e) Teaching any subject associated with administer insulin (psychomotor domain),
health promotion and illness prevention. and facilitating a group session of adolescents
(f) Counseling. discussing and role-playing how to say no when
(g) Advocating for a client. pressured to engage in alcohol or drug misuse
(h) Encouraging a client to express (affective domain).
concerns and feelings. c. See Table 8.1, “Understanding Learning
(i) Encouraging coughing and deep Domains,” in Chapter 8, Teaching and
breathing. Learning, for more information about the
(j) Referring a client to community various learning domains and related nursing
resources. strategies.
c. Interdependent nursing interventions. 3. Responding to life-threatening events.
(1) Nurses work in collaboration with pri- a. Nurses use clinical judgment to identify and
mary health-care providers to implement respond to life-threatening changes in a client’s
dependent nursing interventions that have condition.
set parameters. b. The related interventions generally are associ-
(2) Some settings, such as intensive care units ated with meeting a client’s basic physiological
and birthing units, have standing protocols needs.
that delineate the parameters within which c. Examples include performing abdominal
the nurse can implement a dependent thrusts for a client who is choking, implement-
nursing intervention. ing cardiopulmonary resuscitation for a client
(3) Examples of interdependent nursing inter- who has no palpable pulse and is not breathing,
ventions include: and discontinuing a blood transfusion when
(a) A prescription says, “Out of bed as a client has clinical indicators of a transfusion
tolerated.” The nurse determines reaction.
whether the client is tolerating an 4. Implementing health promotion and illness
activity and therefore the amount of prevention activities.
activity in which to engage the client. a. Nurses provide interventions that assist
(b) A prescription for a pain medication people to maintain health and avoid health
states, “acetaminophen (Tylenol) problems.
650 mg every 6 hours prn for mild b. They aim to help people who are at an increased
lower back pain.” The nurse assesses risk for illness because of their developmental
the level of the client’s pain and then level, such as neonates, young children, and
decides whether to administer the dependent older adults. In addition, they help
prescribed dose. people who are at an increased risk for negative
B. Types of nursing interventions consequences of their behaviors, such as people
1. Assisting with ADLs. who smoke, drink alcohol excessively, misuse
a. Nurses assist clients with activities that people drugs, have multiple sexual partners, or overeat.
perform daily to promote comfort, health, and They also aim to help people limit exacerbations
well-being. of illnesses and subsequent health problems
b. Problems interfering with these actions can as a result of an initial illness.
be acute or chronic, temporary or permanent, c. Examples include administering a vaccine,
and require teaching or assistance to restore teaching a class about healthy nutrition, pro-
function. moting smoking cessation or weight reduction,
c. Examples include helping a debilitated client using standard precautions, and turning and
eat, ambulating a client after surgery, providing positioning an immobile client.
range-of-motion exercises, turning and posi- 5. Performing technical skills.
tioning a bed-bound client, and dressing and a. Nurses must competently perform technical
toileting a client. psychomotor skills associated with a procedure.
6069_Ch06_133-160 14/03/17 5:42 pm Page 146

146 Unit 2 Essential Nursing Care Concepts

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.
6069_Ch06_133-160 14/03/17 5:42 pm Page 147

Chapter 6 Critical Thinking and the Nursing Process 147

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.
6069_Ch06_133-160 14/03/17 5:42 pm Page 148

148 Unit 2 Essential Nursing Care Concepts

CASE STUDY: Put ting It All Together

A primary nurse is admitting an older adult to a surgical The client told the nurse, “I’ve been taking Hytrin
unit before surgery for prostate cancer. The primary 2 mg at bedtime for the past six months because I was
health-care provider tells the nurse that the client was getting up so many times at night to urinate. I started to
admitted early to ensure that the client is well hy- feel bloated and uncomfortable in the abdominal area
drated and that electrolytes are within the expected several weeks ago and did not feel that I completely
range in preparation for surgery. The nurse assesses the emptied my bladder after urinating. I finally went to
client and collects the following information: the doctor, who ran tests and said I have prostate
a. Skin is pale, dry, warm, intact, and tenting when cancer.” The client explained that his doctor then
pinched. referred him to a urologist, who planned to do a
b. Capillary refill is delayed and nailbeds are pale. total prostatectomy in the morning. The client stated,
c. Vital signs: apical pulse 95 beats/min, respirations “Sometimes I need to go to the bathroom and I don’t
23 breaths/min with a slight expiratory wheeze; make it in time and I wet myself. It’s embarrassing and I
temperature 97.8°F using a temporal scanner ther- feel terrible. I’m afraid that I might become impotent
mometer (infrared sensor), and blood pressure and have incontinence after the surgery, but I trust the
160/86 mm Hg. urologist and recognized that the surgery is necessary.”
d. Vesicular breath sounds are present. The client asked many questions about what he can
e. Hyperactive bowel sounds are present. expect after surgery, which were answered. He said,
f. Slight abdominal distention is present over the “Having cancer puts a big monkey wrench into my
suprapubic area. retirement plans. I hope I’ll live long enough to do a
g. Tympany is noted on percussion of the abdomen. little traveling.” The wife stated, “I don’t care if we can’t
h. No lower extremity edema is present. travel. I don’t want him to die. Also, he forgot to tell
i. Speech is rapid and at times tremulous. you that he is always tired because he keeps getting
j. Client appears clean and well groomed, with an up at night to go to the bathroom.” During the inter-
absence of body and breath odor. view, the client went to the bathroom and voided
When the nurse interviews the client, the client’s 200 mL of dark amber urine. A urine specimen was
wife remains at the bedside at the client’s request. sent to the laboratory for a urinalysis. After the inter-
The nurse documents the following information on view, the nurse obtained a drug handbook and reviewed
the nursing admission history and physical: the side effects of Hytrin.

Case Study Questions

A. Identify the objective data collected by the nurse.







6069_Ch06_133-160 14/03/17 5:42 pm Page 149

Chapter 6 Critical Thinking and the Nursing Process 149

CASE STUDY: Put ting It All Together cont ’d

Case Study Questions

B. Identify the subjective data collected by the nurse during the client interview.








C. Identify whether the client, wife, primary health-care provider, and nurse are primary, secondary, or tertiary sources of data.