Critical Thinking, The Nursing Process, and Clinical Judgment PDF

8
Critical Thinking, the Nursing

Process, and Clinical Judgment
Beth Perry Black CHAPTER
LEARNING OUTCOMES
After studying this chapter, students will be able to: • Explain the differences between independent, inter-
• Define critical thinking dependent, and dependent nursing actions
• Describe the importance of critical thinking in nursing • Describe evaluation and its importance in the nursing
• Contrast the characteristics of “novice thinking” with process
those of “expert thinking” • Define clinical judgment in nursing practice and
• Explain the purpose and phases of the nursing process xplain how it is desveloped
e
• Differentiate between nursing orders and medical • Devise a personal plan to use in developing sound
orders clinical judgment
Almost every encounter a nurse has with a patient of 3 years of work by Facione and others who syn-
is an opportunity for the nurse to assist the patient thesized the work of numerous persons who had
to a higher level of wellness or comfort. Whether defined critical thinking. In his essay “Critical
or not this actually happens depends in large mea- Thinking: What It Is and Why It Counts,” Facione
sure on the nurse’s ability to think critically about (2006) suggested that giving a definition of critical
the patient’s particular needs and how best to meet thinking that can be memorized by the learner is
them. It also depends on the nurse’s ability to use actually antithetical to critical thinking! This means
a reliable cognitive approach that leads to sound that the very definition of critical thinking does not
clinical decisions about what the patient’s priority lend itself to simplistic thinking and memorization.
nursing needs are. This chapter explores several Paul and Elder’s (2005) definition of critical thinking
important and interdependent aspects of thinking is similar: “Critical thinking is a process by which the
and decision making in nursing: critical thinking, thinker improves the quality of his or her thinking by
the nursing process, and clinical judgment. skillfully taking charge of the structures inherent in
thinking and imposing intellectual standards upon
them.” They go on to describe a “well-cultivated crit-
DEFINING CRITICAL THINKING
ical thinker” as one who does the following:
Defining critical thinking is a complex task that • Raises questions and problems and formulates
requires an understanding of how people think them clearly and precisely
through problems. Educators and philosophers • Gathers and assesses relevant information,
struggled with definitions of critical thinking for using abstract ideas for interpretation
several decades. In 1990 the American Philosophi- • Arrives at conclusions and solutions that are
cal Association’s Committee on Pre-College Philoso- well-reasoned and tests them against relevant
phy published an expert consensus statement (Box standards
8-1) describing critical thinking and the ideal critical • Is open-minded and recognizes alternative
thinker. This expert statement was the culmination ways of seeing problems, and has the ability to
171
172 Chapter 8 n Critical Thinking, the Nursing Process, and Clinical Judgment
Box 8-1 Expert Consensus Statement rofessional nursing responsible and accountable
p
Regarding Critical Thinking and the for your own decisions, the development of critical
Ideal Critical Thinker thinking skills is crucial as you provide nursing care
We understand critical thinking (CT) to be pur- for patients with increasingly complex conditions.
poseful, self-regulatory judgment that results in Critical thinking skills provide the nurse with a pow-
interpretation, analysis, evaluation, and inference, erful means of determining patient needs, interpret-
as well as explanation of the evidential, conceptual, ing physician orders, and intervening appropriately.
methodological, criteriological, or contextual con- Box 8-2 presents an example of the importance of
siderations upon which that judgment is based. CT critical thinking in the provision of safe care.
is essential as a tool of inquiry. As such, CT is a lib-
erating force in education and a powerful resource CRITICAL THINKING IN NURSING
in one’s personal and civic life. While not synony-
mous with good thinking, CT is a pervasive and You may be wondering at this point, “How am I ever
self-rectifying human phenomenon. The ideal crit- going to learn how to make connections among all
ical thinker is habitually inquisitive, well-informed, of the data I have about a patient?” This is a com-
trustful of reason, open-minded, flexible, fair- mon response for a nursing student who is just
minded in evaluation, honest in facing personal learning some of the most basic psychomotor skills
biases, prudent in making judgments, willing to in preparation for practice. You need to understand
reconsider, clear about issues, orderly in complex that, just like learning to give injections safely and
matters, diligent in seeking relevant information, maintaining a sterile field properly, you can learn
reasonable in the selection of criteria, focused in to think critically. This involves paying attention to
inquiry, and persistent in seeking results that are as how you think and making thinking itself a focus of
precise as the subject and the circumstances of in- concern. A nurse who is exercising critical thinking
quiry permit. Thus educating good critical think- asks the following questions: “What assumptions
ers means working toward this ideal. It combines have I made about this patient?” “How do I know
developing CT skills with nurturing those disposi- my assumptions are accurate?” “Do I need any
tions that consistently yield useful insights and that additional information?” and “How might I look at
are the basis of a rational and democratic society. this situation differently?”
Nurses just beginning to pay attention to their
From American Philosophical Association: Critical thinking: thinking processes may ask these questions after
a statement of expert consensus for purposes of educational nurse-patient interactions have ended. This is known
assessment and instruction, The Delphi report: research
findings and recommendations prepared for the committee on as reflective thinking. This is the same process
pre-college philosophy, 1990, ERIC Document Reproduction described in Chapter 5 about reflecting on ethical
Services, pp 315-423. dilemmas that you encounter in practice. Reflective
thinking is an active process valuable in learning
assess the assumptions, implications, and con- and changing behaviors, perspectives, or practices.
sequences of alternative views of problems Nurses can also learn to examine their thinking pro-
• Communicates effectively with others as solu- cesses during an interaction as they learn to “think
tions to complex problems are formulated on their feet.” This is a characteristic of expert nurses.
The similarities are evident between Facione’s As you move from novice to expert, your ability to
and Paul and Elder’s definitions: critical thinking think critically will improve with practice. In Chap-
is a process that requires disciplined engagement ter 6 you read about Dr. Patricia Benner (1984,
of the intellect to solve problems most effectively. 1996), who studied the differences in expertise of
You may be asking, “What does this have to do nurses at different stages in their careers, from nov-
with nursing?” The answer is very simple. Mak- ice to expert. So it is with critical thinking; novices
ing good clinical judgments requires excellent think differently than experts. Box 8-3 summarizes
critical thinking skills. For you as a practitioner of the differences in novice and expert thinking.
Critical Thinking in Nursing 173
Box 8-2 Using Critical Thinking Skills to Improve a Patient’s Care

Mr. Smith is a 77-year-old man admitted to your you also know that they are signs of hypokalemia.
general medicine unit with several problems, in- Critical thinking does not stop at noting these is-
cluding dehydration secondary to severe nausea sues, however. Critical thinking requires making
and vomiting and a urinary tract infection. His a judgment about what to do with your concerns.
medication orders include hydrochlorothiazide A nurse not using critical thinking may simply
50 mg q am for mild hypertension, ampicillin 2 g follow physician orders with the expectation that
Mr. Smith will feel better once his dehydration is
q6 hours. His IV order is D5LR at 125 mL/hour.
reversed and his UTI is adequately treated. Using
His laboratory values show a serum potassium your good critical thinking skills, however, you
level of 2.6 mEq/L. You recognize that this is low. come to the conclusion that Mr. Smith may be bet-
Mr. Smith seems weak and lethargic; his urine ter supported with a different approach to his care.
output has been 35 mL/hour for the past 2 hours. You call his physician to discuss your concerns,
You are concerned about him and his condition. describing in detail the “big picture.” The specific,
A nurse using good critical thinking skills will detailed information that you communicate clear-
note the following: the source of his dehydration, ly allows the physician to reconsider Mr. Smith’s
his antibiotic order for his UTI, his low potassium medical regimen and proceed from a more in-
level, his IV rate, his low urinary output, and his formed position. The next day you are pleased to see
daily use of a diuretic known to be associated with Mr. Smith walking in the hall when you come onto
potassium loss. His lethargy and weakness could the unit at the beginning of your shift. He says that
be a product of his age and general condition, but he feels “like a new person.”
Box 8-3 Novice Thinking Compared With Expert Thinking

NOVICE NURSES • Tend to follow standards and policies by rote
• Tend to organize knowledge as separate facts. • Learn more readily when matched with a
Must rely heavily on resources (e.g., texts, supportive, knowledgeable preceptor or mentor
notes, preceptors). Lack knowledge gained
from actually doing (e.g., listening to breath EXPERT NURSES
sounds). • Tend to store knowledge in a highly organized
• Focus so much on actions that they tend to and structured manner, making recall of
forget to assess before acting information easier. Have a large storehouse of
• Need clear-cut rules experiential knowledge (e.g., what abnormal
• Are often hampered by unawareness of breath sounds sound like, what subtle changes
resources look like).
• Are often hindered by anxiety and lack of • Assess and think things through before acting
self-confidence • Know when to bend the rules
• Must be able to rely on step-by-step procedures. • Are aware of resources and how to use them
Tend to focus more on procedures than on the • Are usually more self-confident, less anxious,
patient response to the procedure. and therefore more focused
• Become uncomfortable if patient needs • Know when it is safe to skip steps or do two steps
preclude performing procedures exactly as they together. Are able to focus on both the parts (the
were learned procedures) and the whole (the patient response).
• Have limited knowledge of suspected problems; • Are comfortable with rethinking a procedure
therefore they question and collect data more if patient needs require modification of the
superficially procedure
(Continued)
Box 8-3 Novice Thinking Compared With Expert Thinking—cont’d

• Have a better idea of suspected problems, • Are challenged by novices’ questions,
allowing them to question more deeply and clarifying their own thinking when teaching
collect more relevant and in-depth data novices
• Analyze standards and policies, looking for
ways to improve them
From Alfaro-LeFevre R: Critical thinking in nursing: a practical approach, ed 2, Philadelphia, 1999, WB Saunders. Reprinted
with permission.
Box 8-4 Self-Assessment: Critical Thinking Critical thinking in nursing, however, involves
Directions: Listed below are 15 characteristics
more than good problem-solving strategies. It is
of critical thinkers. Mark a plus sign (+) next to
a complex, purposeful, disciplined process that
those you now possess, mark IP (in progress)
has specific characteristics that make it differ-
next to those you have partially mastered, and
ent from run-of-the-mill problem solving. Con-
mark a zero (0) next to those you have not yet
sciously developed to improve patient outcomes,
mastered. When you are finished, make a plan
critical thinking by the nurse is driven by the
for developing the areas that need improvement.
needs of the patient and family. Critical thinking
Share it with at least one person, and report on
in nursing is undergirded by the standards and
progress weekly.
ethics of the profession. Nurses who think criti-
cally seek to build on patients’ strengths while
CHARACTERISTICS OF CRITICAL honoring patients’ values and beliefs (Alfaro-
THINKERS: HOW DO YOU MEASURE LeFevre, 1999). They are engaged in a process of
UP? constant evaluation, redirection, improvement,
______ Inquisitive/curious/seeks truth
and increased efficiency. Be aware that criti-
______ Self-informed/finds own answers
cal thinking involves far more than stating your
______ Analytic/confident in own reasoning
opinion. You must be able to describe how you
skills
came to a conclusion and support your conclu-
______ Open-minded
sions with explicit data and rationales. This is a
______ Flexible
different way of thinking for most people and
______ Fair-minded
requires practice. Dimensions of critical think-
______ Honest about personal biases/self-aware
ing include both cognitive skills and “habits
______ Prudent/exercises sound judgment
of the mind” (Scheffer and Rubenfeld, 2000).
______ Willing to revise judgment when new
Box 8-4 summarizes these characteristics and
evidence warrants
offers an opportunity for you to evaluate your
______ Clear about issues
progress as a critical thinker.
______ Orderly in complex matters/organized
An excellent continuing education self-
approach to problems
study module designed to improve your ability
______ Diligent in seeking information
to think critically can be found online (http://
______ Persistent
www.nurse.com/ce/CE168-60/Improving-Your-
______ Reasonable
Ability-to-Think-Critically/). Continuing one’s
______ Focused on inquiry
education through lifelong learning is an excellent
way to maintain and enhance your critical think-
ing skills. The website http://www.nurse.com has
more than 500 continuing education opportuni-
ties available online and may be helpful to you
as you seek to increase your knowledge base and
The Nursing Process: an Intellectual Standard 175
CRITICAL THINKING Challenge 8-1

Six Caps
This is an hour-long group activity designed to Read the case study below (or one prepared by
clarify the various types of thinking that constitute your teacher), and discuss it from the viewpoint
critical thinking. For every six participants, you of each “cap.” Identify issues for reflection. Then
will need six pieces of colored paper (one white, switch “thinking caps.” Discuss the case study
one red, one black, one yellow, one green, and one again. How easy or difficult was it to change your
blue). You will also need six straight pins. Divide type of thinking? Do some types of thinking come
the group into smaller groups of six and give each more naturally to you than others? Which ones will
group member a pin and piece of colored paper. you have to work to develop? Do you see value in
Each person draws a cap on the paper and pins it each type of thinking? When the group reconvenes,
to his or her shirt in plain view. These represent summarize what you have learned on a flip chart.
the six “thinking caps,” that is, the various types of
thinking to be explored: CASE STUDY FOR SIX CAPS
White cap—Information. Asks the questions, Marianne is a 79-year-old woman who was admit-
“What information do we have, what is needed, ted to the emergency department yesterday with
and how can we get it?” a severe headache. Shortly after admission, she
Red cap—Feelings, intuition, and emotion. Asks became unresponsive; a brain scan revealed she
the questions, “What are we, the patient, and the had experienced a hemorrhagic stroke. Marianne’s
family feeling, and how do we know?” pupils are dilated and do not respond to light; she
Black cap—Policies, codes, standards, protocols, is breathing with the assistance of a respirator. Her
laws. Asks the questions, “What are the standards elderly husband and three adult children are all as-
we should consider, and what are the risks?” sembled. The physician has recommended surgery
Yellow cap—Optimism. Asks the questions, to remove the blood clot but cannot offer much as-
“What are the benefits, who benefits, and what are surance that she will recover function. She has no
the values being expressed?” advance directives, but her husband wants to “try
Green cap—Growth. Asks the questions, “Why everything.” The children believe that she would
don’t we try it this way?” and “What are some dif- not want to undergo this surgery only to be kept
ferent alternatives?” alive with poor quality of life, which they agree is
Blue cap—Focuses on thinking. Asks the ques- the likely outcome. The ethics committee is assem-
tions, “How are we going to proceed in think- bled to assist the family in making the decision.
ing through this situation?” and “What have we Before meeting with the family, the committee
achieved and what do we want to achieve?” meets to discuss the situation.
Modified from De Bono E: Edward de Bono’s mind pack, London, 1995, Dorling-Kindersley; Kenney LJ: Using Edward de Bono’s six hats
game to aid critical thinking and reflection in palliative care, Int J Palliat Nurs 9(3):105-112, 2003.
improve your clinical judgment. In addition, you

can also begin to learn about the many facets of
THE NURSING PROCESS:
critical thinking by participating with classmates
AN INTELLECTUAL STANDARD
in the Critical Thinking Challenge, Six Caps, Critical thinking requires systematic and dis-
below. This exercise will allow you to practice ciplined use of universal intellectual standards
thinking through the various questions that need (Paul and Elder, 2005). In the practice of nursing,
to be asked in response to very complex patient the nursing process represents a universal intel-
and family issues. lectual standard by which problems are addressed
and solved. The nursing process is a method of was considered to be within the scope of prac-
critical thinking focused on solving patient prob- tice of physicians only. Although nurses were
lems in professional practice. The nursing pro- not equipped to diagnose medical conditions
cess is “a designated series of actions intended to in patients, nurses recognized that there were
fulfill the purposes of nursing” (Yura and Walsh, human responses amenable to independent nurs-
1983). ing intervention. These responses could be identi-
A simple example of using a process approach fied (diagnosed) through the careful application
to problem solving is illustrated by examining a of specific defining characteristics. In 1973, the
daily decision that you and most other people National Group for the Classification of Nurs-
face: how to dress for the day. Before putting on ing Diagnosis published its first list of nursing
your clothes, there are several factors you need diagnoses. This organization is now known as
to consider. What is the expected temperature? NANDA International (NANDA-I; NANDA is
Will it be clear, raining, or snowing? How much the acronym for North American Nursing Diag-
time will be spent outdoors? Are there any activi- nosis Association). Its mission is to “facilitate the
ties planned that require special dress? Next, you development, refinement, dissemination and use
probably look at the possible clothing choices. of standardized nursing diagnostic terminology”
Some clothes may be out of season, and others with the goal to “improve the health care of all peo-
need repairs, are too dressy or casual, or do not ple” (http://www.nanda.org). In December 2008,
fit quite right. After considering the environmen- NANDA-I published its 2009-2011 edition of
tal factors, the day’s activities, and your mood, Nursing Diagnoses: Definitions and Classifications.
you select the day’s clothing. After dressing, you Currently, NANDA-I has 206 diagnoses approved
may look in a mirror to evaluate how you look. for clinical testing and has recently added 21 new
You may then modify your outfit on the basis of diagnoses and 9 revised diagnoses. Some of the
your image in the mirror. At this point, you have new diagnoses include “impaired comfort,” “dys-
solved the problem of clothing yourself. You have functional gastrointestinal motility,” and “ineffec-
identified a problem, considered various factors tive peripheral tissue perfusion.” Diagnoses are
related to the problem, identified possible actions, also retired if it becomes evident that their use-
selected the best alternative, evaluated the success fulness is limited or outdated, such as the newly
of the alternative selected, and made adjustments retired diagnosis “disturbed thought processes.”
to the solution based on the evaluation. This is the Here is a simple example of how one of the
same general process nurses use in solving patient newly approved nursing diagnoses may be used:
problems through the nursing process.
Two days after a surgery for a large but be-
For individuals outside the profession, nurs-
nign abdominal mass, Mr. Pierce has not yet
ing is commonly and simplistically defined in
been able to tolerate solid food and has dimin-
terms of tasks nurses perform (e.g., give injec-
ished bowel sounds. His abdomen is some-
tions). Many students get frustrated with activi-
what distended. Your diagnosis is that Mr.
ties and courses in nursing school that are not
Pierce has dysfunctional gastrointestinal mo-
focused on these tasks, believing themselves that
tility. This diagnosis is based on NANDA-I’s
the tasks of nursing are nursing. Even within the
(2008) taxonomy because you have deter-
profession, the intellectual basis of nursing prac-
mined that the risk factors and physical signs
tice was not articulated until the 1960s, when
and symptoms associated with this diagnosis
nursing educators and leaders began to identify
apply to him.
and name the components of nursing’s intellec-
tual processes. This marked the beginning of the A more detailed discussion of nursing diagno-
nursing process. sis is located in the next section of this chapter.
In the 1970s and 1980s, debate about the use The nursing process as a method of clinical
of the term diagnosis began. Until then, diagnosis problem solving is taught in schools of nursing
Phases of the Nursing Process 177
across the United States, and many states refer to she can provide a quiet environment in which
it in their nurse practice acts. The nursing pro- the patient may rest. An expert nurse would real-
cess has sometimes been the subject of criticism ize that the family may be a source of distraction
among nurses. In recent years some nursing lead- from the pain or may be a source of comfort in
ers have questioned the use of the nursing pro- ways that the nurse may not be able to provide.
cess, describing it as linear, rigid, and mechanistic. The expert nurse, in addition to assessing the
They believe that the nursing process contributes patient, is willing to consider alternative explana-
to linear thinking and stymies critical thinking. tions and interventions, enhancing the possibility
They are concerned that the nursing process for- that the patient’s pain will be relieved.
mat, and rigid faculty adherence to it, encourages
students to copy from published sources when Phase 1: Assessment
writing care plans, thus inhibiting the develop- Assessment is the initial phase or operation in the
ment of a holistic, creative approach to patient nursing process. During this phase, information
care (Mueller, Johnston, and Bligh, 2002). Cer- or data about the individual patient, family, or
tainly the nursing process can be taught, learned, community are gathered. Data may include physi-
and used in a rigid, mechanistic, and linear man- ologic, psychological, sociocultural, developmen-
ner. Ideally, the nursing process is used as a cre- tal, spiritual, and environmental information. The
ative approach to thinking and decision making patient’s available financial or material resources
in nursing. Because the nursing process is an inte- also need to be assessed and recorded in a stan-
gral aspect of nursing education, practice, standard format; each institution usually has a slightly
dards, and practice acts nationwide, learning to different method of recording assessment data.
use it as a mechanism for critical thinking and as
a dynamic and creative approach to patient care Types of data
is a worthwhile endeavor. Despite reservations Nurses obtain two types of data about and from
among some nurses about its use, the nursing patients: subjective and objective. Subjective data
process remains the cornerstone of nursing stan- are obtained from patients as they describe their
dards, legal definitions, and practice and, as such, needs, feelings, strengths, and perceptions of the
should be well understood by every nurse. problem. Subjective data are frequently referred
to as symptoms. Examples of subjective data are
statements such as, “I am in pain” and “I don’t
PHASES OF THE NURSING PROCESS
have much energy.” The only source for these
Like many frameworks for thinking through data is the patient. Subjective data should include
problems, the nursing process is a series of orga- physical, psychosocial, and spiritual information.
nized steps, the purpose of which is to impose Subjective data can be very private. Nurses must
some discipline and critical thinking on the pro- be sensitive to the patient’s need for confidence in
vision of excellent care. Identifying specific steps the nurse’s trustworthiness.
makes the process clear and concrete but can Objective data are the other types of data
cause nurses to use them rigidly. Keep in mind that the nurse will collect through observation,
that this is a process, that progression through the examination, or consultation with other health
process may not be linear, and that it is a tool to care providers. These data are measurable, such
use, not a road map to follow rigidly. More cre- as pulse rate and blood pressure, and include
ative use of the nursing process may occur by observable patient behaviors. Objective data are
expert nurses who have a greater repertoire of frequently called signs. An example of objec-
interventions from which to select. For example, tive data that a nurse might gather includes the
if a newly hospitalized patient is experiencing a observation that the patient, who is lying in bed,
great deal of pain, a novice nurse might proceed is diaphoretic, pale, and tachypneic, clutching his
by asking family members to leave so that he or hands to his chest.
Pa
rds
(P
ti
e)
co
en
r im
urc
Re
t In
ar y
So
ter
al
dic
So
ry
vie
r tia
Me
urc
(Te
e)
Physical Examination Other Health Care Providers
Assessment
(Secondary Source) (Tertiary Source)
Sig
(S
ers
nif
e)
ec
ica
urc
mb
on
nt
da
So
Me
Ot
ry
ry
ily
he
So
da
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Fa
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(S
Figure 8-1 Patient data originate from primary, secondary, and tertiary sources.
Objective data and subjective data usually are Sources of patient data
congruent; that is, they usually are in agreement. Patient data can be obtained from many sources
In the situation just mentioned, if the patient told (Figure 8-1). The patient is considered the only
the nurse, “I feel like a rock is crushing my chest,” primary source. Sources of data such as the
the subjective data would substantiate the nurse’s nurse’s own observations or reports of family and
observations (objective data) that the patient is friends of the patient are considered secondary
having chest pain. Occasionally subjective and sources. Tertiary sources of data include medi-
objective data are in conflict. A stark example of cal records and information gathered from other
incongruent subjective and objective data well- health care providers such as physical therapists,
known to labor and delivery nurses is when a physicians, or dietitians.
pregnant woman in labor describes ongoing fetal
activity (subjective data); however, there are no Methods of collecting patient data
fetal heart tones (objective data), and the infant A number of methods are used when collecting
is stillborn. Incongruent objective and subjective patient data. The patient interview is a primary
data require further careful assessment to ascer- means of obtaining both subjective and objec-
tain the patient’s situation more completely and tive data. The interview typically involves a face-
accurately. Sometimes incongruent data reveal to-face interaction with the patient that requires
something about the patient’s concerns and fears. the nurse to use the skills of interviewing, obser-
To get a clearer picture of the patient’s situation, vation, and listening (Figure 8-2). Many factors
the nurse should use the best communication influence the quality of the interview, including
skills he or she possesses to increase the patient’s the physical environment in which the interac-
trust, which will result in more openness. tion occurs. If the patient is not in a private room,
patient data. Abdellah’s 21 nursing problems,

Henderson’s 14 nursing problems, Yura and
Walsh’s human needs approach, and Gordon’s 11
functional health patterns are commonly used
frameworks for collecting and organizing patient
data. Contemporary nursing theorists continue to
develop other organizing frameworks, including
those of Madeleine Leininger, Sister Callista Roy,
Dorothy Orem, and others you will read about in
Chapter 13. Nurses choose different methods of
organizing patient data depending on personal
preference and the method used in the agencies
Figure 8-2 A face-to-face interview with a patient is a
primary means of collecting data and requires good inter- where they are employed.
viewing skills, observation, and listening.
Confidentiality of patient data
A word of caution is needed in regard to patient
the open exchange of information may not occur data. Earlier, it was mentioned that patients con-
easily. Sometimes the presence of family members fide personal information to nurses only if they
constrains the flow of information from a patient, believe the nurse is trustworthy. Patients need to
especially when dealing with sensitive or pri- know and trust that nurses share such informa-
vate issues. Similarly, if an interview takes place tion only with the other treatment team members.
in a cold, noisy, or public place, the type of data Nurses must respect patients’ privacy rights and
obtained may be affected by environmental dis- should never discuss patient information with
tractions. Internal factors related to the patient’s anyone who does not have a work-related need
condition may influence the amount and the type to know. This is not only an ethical issue but also
of data obtained. For example, when interview- a legal issue. Patients’ privacy is now protected by
ing a patient who is having difficulty breathing, Federal law (see Health Insurance Portability and
the verbal data obtained by the interview may Accountability Act [HIPAA] on page 89).
be limited, but careful observation and attentive Ensuring patients’ privacy is complicated in
listening can yield much information about the that vast amounts of patient data may be stored
patient’s condition. digitally and retrieved relatively easily. Although
Physical examination is the second method for the issues of confidentiality and access to elec-
obtaining data. Nurses use physical assessment tronically stored data have yet to be fully resolved,
techniques of inspection, auscultation, percus- each nurse should be entrusted never to violate a
sion, and palpation to obtain these data. A third patient’s privacy by revealing patient information
method of obtaining data is through consultation. except to other members of that patient’s treat-
Consultation is discussing patient needs with ment team.
health care workers and others who are directly
involved in the care of the patient. Nurses also Phase 2: Analysis and Identification
consult with patients’ families to obtain back- of the Problem
ground information and their perceptions about During the data-gathering phase of the nursing
the patients’ needs. process, nurses obtain a great deal of informa-
tion about their patients. These data must first be
Organizing patient data validated and then compared with norms to sort
Once patient data have been collected, they must out data that might indicate a problem or iden-
be sorted or organized. A number of methods tify a pattern. Next, the data must be clustered
have been developed to assist nurses in organizing or grouped so that problems can be identified
and their cause discerned. Knowledge from the nursing diagnoses and interventions based on the
science of nursing, biologic sciences, and social requirements of the medical condition (diabetes)
sciences enables nurses to observe relationships that caused the patient to seek care.
among various pieces of patient data. This process Although nursing diagnosis is still used in
is known as data analysis and results in the iden- nursing, it does not have universal support
tification of one or more problems that are ame- among various constituencies of the discipline
nable to nursing intervention. The problems are and profession. Critics believe that the language
often characterized as nursing diagnoses. In 1976, of nursing diagnosis obscures rather than clarifies
Gordon defined nursing diagnosis as “actual or patient problems. This causes confusion between
potential health problems which nurses, by vir- disciplines involved in care of patients. For
tue of their education and experience, are capable instance, Mr. Pierce, in the earlier example, may
and licensed to treat” (p. 1299). In 1990, NANDA have a simple postoperative ileus. This is a medi-
defined nursing diagnosis as making “a clinical cal diagnosis, but its management has important
judgment about individual, family, or community implications for nursing. The nursing diagnosis
responses to actual or potential health problems/ “dysfunctional gastrointestinal motility related
life processes (which) provide the basis for selec- to decreased motor activity status post abdomi-
tion of nursing interventions to achieve outcomes nal surgery,” with its accompanying “impaired
for which the nurse is accountable.” comfort related to intolerance of medications”
is a very long way of saying that Mr. Pierce has
Distinctions between medical and nursing an ileus, has not been moving around, is in pain
diagnosis and not tolerating his medications. This more
Nursing diagnosis is different from medical diag- streamlined description of Mr. Pierce’s clinical
nosis and was never intended to be a substitute for condition is recognizable across disciplines, and
it. Rather than focusing on what is wrong with the the implications for nursing management remain
patient in terms of a disease process, a nursing diag- the same. In 2008, the American Association of
nosis identifies the problems the patient is experi- Colleges of Nursing (AACN) issued an executive
encing as a result of the disease process, that is, the summary, “The Essentials of Baccalaureate Edu-
human responses to the illness, injury, or threat. cation for Professional Nursing Practice,” which
An important difference between nursing is described in Chapter 7. This summary empha-
diagnosis and medical diagnosis is that nursing sizes patient-centered care in interprofessional
diagnoses address patient problems that nurses teams, which requires excellent communication
can treat within their scope of practice. Propo- across disciplines. Particular emphasis is placed
nents of nursing diagnosis argue that it does little on the translation of evidence into practice. Nurs-
good for nursing diagnoses to include “appendi- ing diagnosis is not mentioned among the nine
citis” because appendicitis is a medical diagnosis essentials. The complete summary can be found
requiring surgery, and nurses may not perform on the AACN website (http://www.aacn.nche.
surgery. A nursing diagnosis for a patient after edu/Publications/positions/index.htm).
an appendectomy might be “ineffective airway Despite a new focus on evidence-based prac-
clearance related to incisional pain.” Because tice, the need for interdisciplinary collaboration,
it is within the scope of practice in all states for and interprofessional teamwork, many schools of
nurses to provide comfort measures and to assist nursing still teach NANDA-I nursing diagnoses,
patients to cough and deep breathe, this would be and many advanced practice nurses use them in
an appropriate nursing diagnosis that is remedied their own practices. NANDA-approved nursing
by nursing interventions. The medical diagnosis diagnoses consist of five components (NANDA,
becomes a platform from which nursing diagno- 2003, pp. 263-264):
ses are developed: a patient with a new medical 1. Label: Concise term or phrase that names the
diagnosis of diabetes will have some very specific diagnosis
2. Definition: Term or phrase that clearly delin- Box 8-5 Writing Nursing Diagnoses
eates meaning and helps differentiate from P = Problem (NANDA-I diagnostic label)
similar diagnoses E = Etiology (causal factors)
3. Defining characteristics: Clusters of observable S = Signs and symptoms (defining characteristics)
cues or inferences
4. Risk factors: Factors that increase vulnerability
to an unhealthful event
5. Related factors: Factors that precede, are asso- The E part of the statement stands for etiology,
ciated with, or relate to the diagnosis or cause, and begins with the words “related to.”
All nursing diagnoses must be supported by These related factors are conditions or circum-
data, which NANDA-I refers to as defining char- stances that can cause or contribute to the devel-
acteristics, also known as signs and symptoms. opment of the problem. To extend the previous
Remember that a sign is observable and is objec- example, “ineffective breathing pattern related
tive, whereas a symptom is reported by the patient to anxiety,” explains the cause of the ineffective
and is subjective. An easy way to understand the breathing pattern as the patient’s high anxiety
difference is to remember the difference between level. The etiology part of the statement is impor-
the words in the commonly used phrase “nausea tant, because if the cause were decreased energy
and vomiting.” Nausea is a subjective report of or fatigue rather than anxiety, the nurse would
a specific feeling by a patient but is not directly need to select different nursing actions to solve the
observable by the nurse. Vomiting, on the other problem. A diagnosis may be technically correct,
hand, is objective, verifiable, and quantifiable. It but, if the etiology is incorrect, interventions are
is a clear sign that the patient’s report of nausea likely to be ineffective. In early 2009, NANDA-I
(a symptom) was correct. issued a position statement that the “related to”
Accurate diagnosis of human responses is field in nursing diagnosis is an effective teaching
very important. All nursing actions flow from strategy but may be too complex to be practi-
the diagnosis, and inaccurate diagnoses can cal in clinical practice. Hence its new position is
lead to lost time and wasted resources and that just the diagnostic label may be acceptable.
may endanger the patient. Accuracy of diagno- NANDA-I also notes in this statement that some
sis is a professional behavior, one of nursing’s electronic care plan systems may not be amena-
accountabilities (Lunney, 2001). Lunney (2008) ble to the inclusion of “related to” factors (http://
wrote an appeal to nurses in practice and edu- www.nanda.org).
cation to address this issue of diagnostic accu- The last part of the diagnostic statement is
racy based on research findings that there is a S, which stands for signs and symptoms, or as
need for more diagnostic consistency among NANDA-I refers to them, “defining characteris-
nurses, that the issue of accuracy will always tics.” Thus the complete diagnostic statement for
be present because of the complexities of nurs- our sample diagnosis might be “ineffective breath-
ing, and that electronic health records make ing patterns related to anxiety as manifested by
the issue of accuracy of diagnosis even more dyspnea, nasal flaring, use of accessory muscles to
broad-based. breathe, and respiratory rate of 24/minute.” Some
nurses use the phrase “as evidenced by” or “AEB”
Writing NANDA-I nursing diagnoses. A to preface to the list of defining characteristics.
format used to write the diagnostic statement,
called the PES format (Box 8-5), was developed Prioritizing nursing diagnoses
by Gordon (1987). In this format, the P stands for After diagnoses are identified, the nurse must put
the concise description of the problem, using the them in order of priority. Two common frame-
NANDA-I diagnostic label, for example, “ineffec- works are used to establish priorities. One of
tive breathing pattern.” these considers the relative danger to the patient.
With use of this framework, diagnoses that are needs. In other words, highest priority is given
life threatening are the nurse’s first priority. Next to diagnoses related to basic physiologic needs.
are those that have the potential to cause harm Diagnoses related to higher-level needs such
or injury. Last in priority are those diagnoses that as love and belonging or self-esteem, although
are related to the overall general health of the important, have priority only after basic physi-
patient. Thus a diagnosis of “ineffective airway ologic needs are met.
clearance” would be dealt with before “sleep pat- Except in life-threatening situations, nurses
tern disturbance,” and “sleep pattern disturbance” should take care to involve patients in identifying
could have priority over “knowledge deficit.” priority diagnoses. Because varied sociocultural
Another framework used to prioritize diagno- factors have a great impact on the manner in which
ses is Maslow’s (1970) hierarchy of needs (refer to patients prioritize problems, nurses must be aware
Chapter 12, Figure 12-2). When this framework of these factors and take them into consideration
is used, there is an inverse relationship between when planning patient care. The nurse’s own cul-
high-priority nursing diagnoses and high-level tural perspective must not take priority over that
of the patient in determining priorities. For exam-
Box 8-6 Bloom’s Taxonomy ple, many maternity nurses are very strong pro-
A taxonomy is a classification system. Bloom, an
ponents of breast-feeding and consider it one of
educator, described types of learning in terms of
their priorities in assisting new mothers to estab-
domains of educational activities. This taxonomy
lish effective breast-feeding patterns. However,
is helpful for nursing:
for some women, breast-feeding is not a cultural
• Psychomotor domain: Involves physical norm or a desirable outcome of new motherhood.
movement and increasingly complex activities
Although it may be difficult to understand for the
in the motor-skill arena. Learning in this
maternity nurse who has expertise in the benefits
domain can be assessed by measures such as
of breast-feeding, imposing the nurse’s cultural
distance, time, and speed.
and professional perspective on the patient is
• Nursing goal: Patient will move from bed unacceptable and can lead to diminished effec-
to chair 3 times today without assistance.
tiveness of nursing care in other domains in which
• Cognitive domain: Involves knowledge the new mother needs assistance.
and intellectual skills. Cognitive skills range Phase 3: Planning
from simple recall to complex tasks such as
synthesis and evaluation.
Planning is the third phase in the nursing pro-
• Nursing goal: Patient will list five signs of cess. Planning begins with identification of
illness in her newborn infant by the date of
patient goals and determination of ways to reach
hospital discharge.
those goals. Goals are used by the patient and the
• Affective domain: Involves the emotions, nurse to guide the selection of interventions and
such as feelings, values, and attitudes.
to evaluate patient progress. Bloom’s taxonomy
• Nursing goal: Patient will describe feeling (as described by Clark, 2001) (Box 8-6) provides
more accepting of new colostomy within
a simple description of domains of learning that
1 week of providing ostomy self-care.
drive the development of patient goals: psycho-
Setting nursing goals using Bloom’s taxonomy motor, cognitive, and affective goals. This taxon-
is a simple way to address three important do- omy identified domains of educational activities
mains of the patient’s needs. A single patient is that are well suited to nursing.
likely to have goals in each of these domains. Just as nursing diagnoses are written in col-
laboration with the patient, goals should also be
Modified from Facione PA: Critical thinking: a statement
of expert consensus for purposes of educational assessment agreed on by both nurse and patient unless col-
and instruction, “The Delphi Report,” Milbrae, Calif, 1990, laboration is impossible, such as when the patient
The California Academic Press. has an altered mental status, is a young child, or
is incapacitated in some way. In that event, fam- a chievement of broader, long-term goals. For
ily members or significant others can collaborate example, “The patient will lose 2 pounds” is a
with the nurse. Goals give the patient, family, short-term goal, and the time limit for accom-
significant others, and nurse direction and make plishment can be brief, perhaps a week or 10
them active partners. days. Long-term goals, however, usually repre-
sent major changes or rehabilitation. A goal such
Writing patient goals and outcomes as “The patient will lose 75 pounds” may take
The terms goal and objective are frequently used months or perhaps even years to accomplish, and
interchangeably. Note that the word objective is the time frame should be set accordingly. Setting
used differently here than its earlier use, when it realistic goals in terms of both outcomes and time
was used as an adjective describing observable is extremely important. Frustration and discour-
and measurable data. In terms of outcomes, the agement can occur when goals are unrealistic in
word objective is a noun and means a goal or spe- outcomes or time.
cific aim of intervention. Goals or objectives are The nurse can be a good resource for help-
statements of what is to be accomplished and are ing patients in determining accessible goals. For
derived from the diagnoses. Because the problem example, assume that your patient is a young
or diagnosis is written as a patient problem, the man with a severely injured thigh and knee from
goal should also be stated in terms of what the a single-car automobile accident. The injury will
patient will do rather than what the nurse will do. require several orthopedic surgeries. To com-
The goal begins with the words “the patient will” plicate matters, he has a nosocomial (hospital-
or “the patient will be able to.” The goal sets a gen- acquired) infection in his surgical site. One
eral direction, includes an action verb, and should day, he mentions to you that his goal is to run a
be both attainable and realistic for the patient. marathon within a year. Running a marathon is
Outcome criteria are specific and make the a worthy goal and is reachable eventually for this
goal measurable. Outcome criteria define the young man. However, as his nurse, you recognize
terms under which the goal is said to be met, par- the importance of setting some short-term goals
tially met, or unmet. Each diagnosis has at least right now that will improve his health and bet-
one patient goal, and each patient goal may have ter the chances of achieving his goal of running
several outcome criteria. Effective outcome crite- a marathon. Your care plan should reflect the
ria state under what conditions, to what extent, short-term, attainable goals (such as walking with
and in what time frame the patient is to act. For a walker the length of the hallway twice a day)
the postoperative patient who had an abdominal that he needs to reach in the meantime that will
procedure, a sample patient goal with outcome move him toward his long-term, personal goal.
criteria might be, “The patient will have effective Cultural congruency is an important consider-
bowel elimination as evidenced by having one ation in setting patient goals and selecting inter-
soft, formed stool every other day without the use ventions. A culturally congruent intervention is
of laxatives or enemas within 2 weeks.” It is easy one that is developed within the broad social,
to see that this goal is written in terms of what the cultural, and demographic context of the patient’s
patient will do (have a bowel movement at least life. The patient is more likely to benefit from an
every other day), is measurable (one soft, formed intervention that is tailored to his or her specific
stool), gives conditions (without the use of laxa- sociocultural needs and interests. Although cul-
tives or enemas), and has a specified time frame tural congruency is an important element to effec-
for accomplishment (2 weeks). tive intervention, the nurse must take care not to
Establishing a time frame for patient goals to stereotype patients or assume that “all ________”
be met is important. Short-term goals may be (fill in the blank) like the same things, will react
attainable within hours or days. They are usu- the same way, or respond to the same intervention.
ally specific and are small steps leading to the The Cultural Considerations Challenge on p. 184
Cultural Considerations Challenge

Impact of Culture on Nursing Interventions
From the Association of Black Nursing Faculty c ommunity and among researchers, who are trying
website (http://www.abnf.net): to determine why this is the case. Theresa Swift-
Scanlan, PhD, RN, whose research is highlighted
“The purpose of the Association of Black Nursing
in Chapter 11, is examining the epigenetics of
Faculty, Inc, (ABNF) is to form and maintain a
breast cancer. It is her hope that this health dispar-
group whereby Black professional nurses with simi-
ity can be eliminated completely through research
lar credentials, interests and concerns may work to
to determine why African-American women have
promote certain health-related issues and educa-
a worse prognosis in breast cancer.
tional interests for the benefit of themselves and the
In the Implications section at the end of the article,
Black community.”
the authors refer to the cultural appropriateness of
An example of the interests and work that have study materials to be used in an intervention. As
developed from the ABNF is found in The ABNF you read this article, consider these questions:
Journal, published six times each year. Volume 17 1. In addition to ethnicity, can you think of other
(1) in 2006 was dedicated to the issue of breast ways that interventions should be made cultur-
cancer in African-American women. The research ally appropriate?
article “Getting Ready: Developing an Educational 2. What might happen if an intervention is not
Intervention to Prepare African American Women culturally appropriate?
for Breast Biopsy” describes the efforts to produce 3. Who determines what is and is not culturally
intervention materials for African-American appropriate?
women preparing to undergo breast biopsies. You can find the article here:
African-American women are more likely to Bradley PK, Berry A, Lang C, Myers RE: Getting
die of breast cancer than are white American ready: developing an educational intervention
women, although fewer black women than white to prepare African American women for breast
women have a diagnosis of breast cancer. This is a biopsy, The ABFN Journal (17)1:15-19, 2006.
source of great concern in the African-American
describes a research report explaining the impor- i llness or medical treatment, whereas medical
tance of having culturally appropriate educational orders are designed to treat the actual illness or
materials to prepare African American women disease. An example of a nursing order is “Teach
for their breast biopsies. turning, coughing, and deep-breathing exercises
prior to surgery.” These activities are designed
Selecting interventions and writing nursing to prevent postoperative respiratory problems
orders caused by immobility. They are appropriate nurs-
After short-term and long-term goals are iden- ing orders because prevention of complications
tified through collaboration between nurse and due to immobility is a nursing responsibility.
patient, the nurse writes nursing orders. Nursing Nursing orders may include instructions about
orders are actions designed to assist the patient consultation with other health care provid-
in achieving a stated goal. Every goal has specific ers, such as the dietitian, physical therapist, or
nursing orders, which may be carried out by a pharmacist.
registered nurse (RN) or delegated to other mem-
bers of the nursing staff. Types of nursing interventions. Nursing
Nursing orders and medical orders differ. interventions are of three basic types: indepen-
Nursing orders refer to interventions that are dent, dependent, or interdependent. Indepen-
designed to treat the patient’s response to an dent interventions are those for which the nurse’s
intervention requires no supervision or direction time spent in generating a completely new plan
by others. Nurses are expected to possess the each time a patient is seen. These plans are easily
knowledge and skills to carry out independent computer generated, with the nurse making selec-
actions safely. An example of an independent tions from menus to individualize the plan to the
nursing intervention is teaching a patient how to particular patient. The amount of time needed to
examine her breasts for lumps. The nurse practice update and document these plans is then vastly
act of each state usually specifies general types of decreased. Computer use also facilitates data col-
independent nursing actions. lection for research.
Dependent interventions do require instruc- Because of the decreasing average length of stay
tions, written orders, or supervision of another for patients in health care facilities, the increasing
health professional with prescriptive authority. focus on achieving timely patient outcomes in the
These actions require knowledge and skills on the specific time frame permitted by reimbursement
part of the nurse but may not be done without systems, and the emphasis by accrediting bodies
explicit directions. An example of a dependent on multidisciplinary care, many agencies adopted
nursing intervention is the administration of the use of multidisciplinary plans of care known
medications. Although a physician or advanced as critical paths, care tracks, or care maps. Criti-
practice nurse must order medications in in- cal paths have been replaced with other types
patient settings, it is the responsibility of the nurse of multidisciplinary care plans in some settings.
to know how to administer them safely and to Multidisciplinary care plans are written in col-
monitor their effectiveness. The nurse also must laboration with physicians and other health care
question orders that he or she feels are incongru- providers and establish a sequence of short-term
ent with safe care or are not within accepted stan- daily outcomes that are easily measured. This
dards of care. type of care planning facilitates communication
The third type, interdependent interventions, and collaboration among all members of the
includes actions in which the nurse must collabo- health care team. It also permits comparisons
rate or consult with another health professional of outcomes between treatment plans, as well as
before carrying out the action. One example of among health care facilities. As with the nursing
this type of action is the nurse implementing process, unyielding adherence to the critical path
orders that have been written by a physician in a without taking a patient’s idiosyncratic responses
protocol. Protocols define under what conditions into consideration can negatively affect patient
and circumstances a nurse is allowed to treat the outcomes and is a detriment to successful nurs-
patient, as well as what treatments are permis- ing care.
sible. They are used in situations in which nurses The development of appropriate plans of care
need to take immediate action without consulting depends on the nurse’s ability to employ critical
with a physician, such as in an emergency depart- thinking. Nurses must be able to analyze infor-
ment, a critical care unit, or a home setting. mation and arguments, make reasoned deci-
sions, recognize many viewpoints, and question
Writing the plan of care and seek answers continuously. At the same time,
Once interventions are selected, a written plan nurses must be logical, flexible, and creative
of care is devised. Some health care agencies use and take initiative while considering the holistic
individually developed plans of care for their nature of each patient.
patients. The nurse creates and develops a plan
for each patient. Others use standardized plans Phase 4: Implementation of Planned
of care that are based on common and recurring Interventions
problems. The nurse then individualizes these Implementation, the fourth phase or operation of
standard plans of care. An advantage of using the nursing process, occurs when nursing orders
standardized plans is that they can decrease the are actually carried out. Most people think of
ursing as “doing something” for or to a patient.

n possible that nursing actions were incorrectly
Notice, however, that in using the nursing pro- implemented.
cess, nurses do a great deal of thinking, analyz- Evaluation is a critical phase in the nursing
ing, and planning before the first actual nursing process and one that is often slighted. The best
action takes place. nursing care plan is one that is evaluated fre-
Professional nurses understand the crucial quently and changed in response to the patient’s
nature of the first three phases of the nursing pro- condition. Sometimes a care plan will reflect all
cess in ensuring that safe and appropriate care of the most common nursing interventions used
occurs. Nurses who forgo these essential phases to treat specific diagnoses; it is not enough, how-
and move immediately into action are not pro- ever, to continue to do the “right things” if the
viding care in a responsible, professional manner. patient is not improving in the expected manner.
Patients feel a greater sense of trust in nurses who If, on evaluation, the problem is not resolving in
are providing care when dependent, independent, a timely way or will not resolve at all, the nursing
and interdependent orders are planned and car- care plan must be revised to reflect the necessary
ried out in an orderly, competent manner. Com- changes.
mon nursing interventions include such actions
as managing pain, preventing postoperative
DYNAMIC NATURE OF
complications, educating patients, and perform-
THE NURSING PROCESS
ing procedures (such as wound care and cath-
eter insertion) that are ordered by other health Although the phases in the nursing process are
care providers. As the nurse carries out planned discussed separately here, in practice they are
interventions, he or she is continually assessing not so clearly delineated nor do they always
the patient, noting responses to nursing inter- proceed from one to another in a linear fashion.
ventions, and modifying the care plan or adding The nursing process (Figure 8-3) is dynamic,
nursing diagnoses as needed. Documentation of meaning that nurses are continuously moving
nursing actions is an integral part of the imple- from one phase to another and then beginning
mentation phase. the process again. Often a nurse performs two
or more phases at the same time, for instance,
Phase 5: Evaluation observing a wound for signs of infection (assess-
Evaluation is the final phase of the nursing ment) while changing the dressing on the wound
process. In this phase, the nurse examines the (intervention) and asking the patient the extent
patient’s progress in relation to the goals and out-
come criteria to determine whether a problem is
resolved, is in the process of being resolved, or is Assessment
unresolved. In other words, the outcome criteria
are the basis for evaluation of the goal. Evaluation Analysis of
data/formulation
may reveal that data, diagnosis, goals, and nurs- of nursing
ing interventions were all on target and that the diagnosis
problem is resolved. Evaluation
Evaluation may also indicate a need for a
change in the plan of care. Perhaps inadequate Nursing care
patient data were the basis for the plan, and fur- planning/
ther assessment has uncovered additional needs. outcomes
identification
The nursing diagnoses may have been incorrect
Implementation
or placed in the wrong order of priority. Patient of care plan
goals may have been inappropriate or unat- Figure 8-3 The nursing process is a dynamic, nonlinear
tainable within the designated time frame. It is tool for critical thinking about human responses.
Dynamic Nature of the Nursing Process 187
to which pain has been relieved by comfort mea- out by looking in the mirror. This comparison
sures (evaluation). reveals that problem solving is something each
Now that you have read about the phases of the person does every day. The use of the nursing
nursing process, we will look back at the open- process simply provides professional nurses with
ing scenario. The problem that was identified a patient-oriented framework with which to solve
was the necessity to wear appropriate clothing. clinical problems.
Data, both objective (the temperature outdoors) An example of using the nursing process in
and subjective (the mood one is in), were gath- a high-priority clinical situation is described
ered. Selection was made and implemented, and in Box 8-7. This case study demonstrates how
an evaluation of the implementation was carried using the nursing process becomes so natural
Box 8-7 Nursing Process Case Study of a High-Priority Diagnosis

You have just received a report from the day shift II. Analysis
about Mr. Burkes. You were told that he had been A. Ineffective airway clearance related to
admitted with a diagnosis of cancer of the tongue copious, thick secretions
and that he had a radical neck dissection yesterday. III. Plan
He has a tracheostomy and requires frequent suc- A. Short-term goal: Patient will maintain
tioning of his secretions. He is alert and responds patent airway as evidenced by absence
by nodding his head or writing short notes. of expiratory wheezes and crackles,
When you enter his room, you note that he is decreased signs of anxiety and air hunger.
apprehensive and tachypneic and is gesturing for B. Long-term goal: Patient will have patent
you to come into the room. You auscultate his airway as evidenced by his ability to clear
lungs and note coarse crackles and expiratory the airway without the use of suctioning
wheezes. You can see thick secretions bubbling by the time of discharge.
out of his tracheostomy. He has poor cough effort.
IV. Implementation
On the basis of these data, you realize that a
priority nursing diagnosis is ineffective airway A. Assess lung sounds every hour for
clearance. You immediately prepare to perform crackles and wheezes.
tracheal suctioning. As you are suctioning, you B. Suction airway as needed.
watch the patient’s nonverbal responses and note C. Elevate head of bed to 45 degrees.
that he is less apprehensive when the suctioning is D. Teach patient abdominal breathing
completed. You also auscultate the lungs and note techniques.
that there are decreased crackles and that the expi- E. Encourage patient to cough out
ratory wheezes are no longer present. Mr. Burkes secretions.
writes “I can breathe now” on his note pad. V. Evaluation
I. Assessment A. Short-term goal: Achieved as evidenced
A. Subjective data by decreased crackles and absent wheezes
1. None because of inability to speak when auscultating the lungs; patient
B. Objective data appears less anxious, indicated by writing
1. Tracheostomy with copious, thick that he “can breathe now”
secretions B. Long-term goal: Will be evaluated before
2. Tachypnea discharge
3. Gesturing for help
4. Coarse crackles and expiratory
wheezes
5. Poor cough effort
that experienced nurses go through the phases what to look for (e.g., elevation of temperature
fluidly and automatically. Although no respon- in a surgical patient), draws valid conclusions
sible nurse would take the time to write out this about possible alternative meanings of signs
care plan in advance of acting on a diagnosis of and symptoms (e.g., postoperative infection,
“ineffective airway clearance,” you should under- atelectasis, dehydration), and knows what to
stand that the nursing process is exactly the same do about it (e.g., listen to breath sounds, assess
for those high-priority nursing situations that for dehydration, check incision for redness and
require immediate action and those that will drainage, seek another opinion, notify the phy-
evolve over time. sician). Developing sound clinical judgment
requires recalling facts, recognizing patterns
in patient behaviors, putting facts and obser-
DEVELOPING CLINICAL JUDGMENT
vations together to form a meaningful whole,
IN NURSING
and acting on the resulting information in an
Becoming an effective nurse involves more than appropriate way.
critical thinking and the ability to use the nurs- Knowing the limitations of your expertise is
ing process. It depends heavily on developing an important aspect of clinical judgment. Most
excellent clinical judgment. Clinical judgment nurses have an instinctive awareness of when they
consists of informed opinions and decisions are approaching the limits of their expertise and
based on empirical knowledge and experience. will seek consultation with other professionals
Nurses develop clinical judgment gradually as needed. Your state’s nurse practice act, health
as they gain a broader, deeper knowledge base agency policies, school policies, and the profes-
and clinical experience. Extensive direct patient sions’ standards of practice all provide guidance in
contact is the best means of developing clinical making the decision about nursing actions within
judgment. your scope of practice. Nursing students, whether
Critical thinking and clinical reasoning new to nursing or RNs in baccalaureate programs,
used in the nursing process are both impor- must consider policies and standards in determin-
tant aspects of clinical judgment. A nurse who ing their scope of practice in any given nursing
has developed sound clinical judgment knows situation.
Box 8-8 Clinical Judgment: Nine Key Questions

1. What major outcomes (observable beneficial have a long list of actual or potential health
results) do we expect to see in this particular problems needing to be structured to set your
person, family, or group when the plan of priorities.
care is terminated? Example: The person 3. What are the circumstances? Who is involved
will be discharged without complications, (e.g., child, adult, group)? How urgent are
able to care for himself, 3 days after the problems (e.g., life threatening, chronic)?
surgery. Outcomes may be addressed on a What are the factors influencing their
standard plan, or you may have to develop presentation (e.g., when, where, and how did
these outcomes yourself. Make sure any the problems develop)? What are the patient’s
predetermined outcomes in standard plans are values, beliefs, and cultural influences?
appropriate to your patient’s specific situation. 4. What knowledge is required? You must know
2. What problems or issues must be addressed problem-specific facts (e.g., how problems
to achieve the major outcomes? Answering usually present, how they are diagnosed,
this question will help you prioritize. You may what their common causes and risk factors
Developing Clinical Judgment in Nursing 189
Box 8-8 Clinical Judgment: Nine Key Questions—cont’d

are, what common complications occur, life-threatening situations, such as cardiac
and how these complications are prevented arrest) and (2) the planned length of contact
and managed); nursing process and related (e.g., if your patient will be hospitalized only
knowledge and skills (e.g., ethics, research, for 2 days, you have to be realistic about what
health assessment, communication, priority can be accomplished, and key decisions need
setting); related sciences (e.g., anatomy, to be made early).
physiology, pathophysiology, pharmacology, 7. What resources can help me? Human
chemistry, physics, psychology, sociology). resources include clinical nurse educators,
You must also be clearly aware of the nursing faculty, preceptors, experienced
circumstances, as addressed in question 3 nurses, advanced practice nurses, peers,
above. librarians, and other health care professionals
5. How much room is there for error? In the (such as pharmacists, nutritionists, physical
clinical setting, there is usually minimal room therapists, physicians). The patient and family
for error. However, it depends on the health of are also valuable resources (usually they know
the individual and the risks of interventions. A their own problems best). Other resources
healthy, young postoperative patient with no include texts, articles, other references,
chronic illnesses may tolerate early mobility computer databases, decision-making
after surgery better than an elderly person support, national practice guidelines,
with a history of multiple chronic problems and facility documents (e.g., guidelines,
requiring numerous medications. Although policies, procedures, assessment
their orders for postoperative ambulation forms).
may be identical and your commitment to 8. Whose perspectives must be considered?
their safe care exactly the same for these two The most significant perspective to consider
patients, excellent clinical judgment based is the patient’s point of view. Other important
on your assessments allows you to conclude perspectives include those of the family and
that the young patient is safe walking in the significant others, caregivers, and relevant
hallway with a family member, whereas the third parties (e.g., insurers).
elderly patient needs your assistance and 9. What is influencing my thinking?
guidance during early ambulation. Identify your personal biases and any
6. How much time do I have? Time frame for other factors influencing your critical
decision making depends on (1) the urgency thinking and therefore your clinical
of the problems (e.g., there is little time in judgment.
From Alfaro-LeFevre R: Critical thinking in nursing: a practical approach, ed 2, Philadelphia, 1999, WB Saunders. Reprinted
with permission.
Alfaro-LeFevre (1999) developed a list of nine Nurses are responsible for developing sound
key questions (Box 8-8) to consider as you seek to clinical judgment and are accountable for their
improve your clinical judgment. Because the goal decisions and nursing practice that arises from
of nursing is to provide the best care to patients those decisions. Your current level of clinical
based on research and clinical evidence, the devel- judgment can always be improved. It would be
opment of excellent clinical judgment is a profes- wise for you to devise a personal plan for improv-
sional responsibility. As you work to gain clinical ing your own clinical decision making. Working
experience and improve your own clinical judg- thoughtfully through the self-assessment in
ment, these questions will help focus your thinking. Box 8-9 will help you begin.
Box 8-9 Self-Assessment: Developing Sound Clinical Judgment

Answer the following questions honestly. When 6. Use resources wisely.
finished, make a list of the items you need to work • Do I look for opportunities to learn from
on in your quest to develop sound clinical judg- others, such as teachers, other experts, or
ment. Keep the list with you and review it fre- even my peers?
quently. Seek opportunities to practice needed • Do I seek help when needed, being mindful
activities. of patient privacy issues?
1. Use references. 7. Know standards of care.
• Do I look up new terms when I encounter • Do I read facility policies, professional
them to make them part of my vocabulary? standards, school policies, and state board of
• Do I familiarize myself with normal findings nursing rules and regulations to determine
so that I can recognize those outside the my scope of practice?
norm? • Do I know the clinical agency’s policies and
• Do I use research findings and base my procedures affecting my particular patients?
practice on scientific evidence? • Do I attempt to understand the rationales
• Do I learn the signs and symptoms of behind policies and procedures?
various conditions, what causes them, and • Do I follow policies and procedures
how they are managed? carefully, recognizing that they are designed
2. Use the nursing process. to help me use good judgment?
• Do I always assess before acting, stay 8. Know technology and equipment.
focused on outcomes, and make changes as • Do I routinely learn how to use patient
needed? technology such as intravenous pumps,
• Do I always base my judgments on fact, not patient monitors, computers?
emotion or hearsay? • Do I learn how to check equipment for
3. Assess systematically. proper functioning and safety?
• Do I have a systematic approach to assessing 9. Give patient-centered care.
patients to decrease the likelihood that I will • Do I always remember the needs and
overlook important data? feelings of the patient, family, and significant
4. Set priorities systematically. others?
• Do I evaluate both the problem and the • Do I value knowing my patients’ health
probable cause before acting? beliefs and values within their own cultural
• Am I willing to obtain assistance from contexts?
a more knowledgeable source when • Do I “go the extra mile” for patients?
indicated? • Do I demonstrate the belief that every
5. Refuse to act without knowledge. patient deserves my very best efforts?
• Do I refuse to perform an action when I
do not know the indication, why it works,
and what risks there are for harm to this
particular patient?
Modified from Alfaro-LeFevre R: Critical thinking in nursing: a practical approach, ed 2, Philadelphia, 1999, WB Saunders,
pp 88-92. Used with permission.
References 191
Summary of Key Points 4. List a short-term career goal for yourself and
a long-term career goal using all the essential
• Critical thinking is a skill that can be learned. elements of effective goals. Evaluate your
In nursing, critical thinking is a purposeful, progress toward these goals.
disciplined, active process that improves clini- 5. Explain the difference between independent,
cal judgment and thereby improves patient dependent, and interdependent nursing inter-
care. ventions and give an example of each.
• Thinking by novice nurses is different from 6. List the pros and cons related to the use of
that of expert nurses in identifiable ways. nursing diagnosis.
• The nursing process is a systematic problem- 7. Explain the difference between medical and
solving framework that ensures that care is nursing diagnoses.
developed in an organized, analytic way. 8. Describe what is meant by the statement, “The
• The phases of the nursing process are assess- nursing process is a cyclic process.”
ment, analysis and diagnosis, planning, imple- 9. Using what you learned about yourself from
mentation, and evaluation. Self-Assessment: Developing Sound Clinical
• Properly used, the nursing process is cyclic and Judgment (Box 8-9), set short-term goals for
dynamic rather than rigid and linear. improvement in each of the nine areas. Make
• Nurses may initially find that using the nurs- a checklist to take to your next clinical experi-
ing process feels awkward or slow. With experience and consciously work on improving your
ence, however, most find it becomes a natural, clinical judgment.
organized approach to patient care.
• Consistent, comprehensive, and coordinated To enhance your understanding of this
patient care results when all nurses use the chapter, try the Student Exercises on the Evolve site
nursing process effectively. at http://evolve.elsevier.com/Chitty/professional.
• Through the use of the nursing process, nurses
are able to work toward resolving patient
problems in a systematic and thorough man-
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research findings and recommendations prepared for
tice and research, understanding your scope
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