1. Identify the problem.
2. Collect data.
3. Formulate a question or hypothesis.
4. Test the question or hypothesis.
5. Evaluate results of the test or study.
• Spend more time during initial patient assessments to observe patient behavior and measure physical findings as a way to improve knowledge of your patients. Determine what is important to them and make an emotional connection. Patients perceive meaningful time as that involving personal rather than task-oriented conversation.
• When talking with patients, listen to their accounts of their experiences with illness, watch them, and come to understand how they typically respond (Tanner, 2006).
• Consistently check on patients to assess and monitor problems to help you identify how clinical changes develop over time.
• Ask to have the same patient assigned to you over consecutive days. Researchers have noted that a nurse-patient relationship develops from getting to know a patient and building a foundation for connecting on the first day of care, to deepening understanding of the patient and sustaining a connection by the second day, to being comfortable with the patient by the third day (Lotzkar and Bottorff, 2010).
• Social conversation and continuity are important for developing knowing and nurse-patient relationships
1. Which experience, situation, or information in your clinical experience is confusing, difficult, or interesting?
2. What is the meaning of the experience? What feelings did you have? What feelings did your patient or family have? What influenced the experience?
3. Do the feelings, guesses, or questions remind you of any experiences from the past or something that you think is a desirable future experience? How does it relate?
4. What are the connections between what is being described and what you have learned about nursing science and theory?
Meeting with Colleagues
• Nurses who apply critical thinking in their work focus on options for solving problems and making decisions rather than rapidly and carelessly forming quick, single solutions.
• Reflection involves purposeful thinking back or recalling a situation to discover its purpose or meaning.
• Following a procedure step by step without adjusting to a patient’s unique needs is an example of basic critical thinking.
• In complex critical thinking a nurse learns that alternative and perhaps conflicting solutions exist.
• In diagnostic reasoning you collect patient data and analyze them to determine the patient’s problems.
• The critical thinking model combines a nurse’s knowledge base, experience, competence in the nursing process, attitudes, and standards to explain how nurses make clinical judgments that are necessary for safe, effective nursing care.
• Clinical learning experiences are necessary for you to acquire clinical decision-making skills.
• Critical thinking attitudes help you know when more information is necessary and when it is misleading and to recognize your own knowledge limits.
• The use of intellectual standards during assessment ensures that you obtain a complete database of information.
• Professional standards for critical thinking refer to ethical criteria for nursing judgments, evidence-based criteria for evaluation, and criteria for professional responsibility.
• Meeting regularly with colleagues allows you to discuss anticipated and unanticipated outcomes in any clinical situation to continually learn and develop your expertise.
• Stress over a prolonged period or when extreme can cause distress, leading to poor work productivity and impaired decision making and communication.
2. The interpretation and validation of data to ensure a complete database
First step of the nursing process. Activities required in the first step are data collection, validation, sorting, and documentation. The purpose is to gather information for health problem identification.
• The patient through interview, observations, and physical examination.
• Family members or significant others’ reports and response to interviews.
• Other members of the health care team.
• Medical record information (e.g., patient history, laboratory work, x-ray film results, multidisciplinary consultations).
• Scientific and medical literature (evidence about disease conditions, assessment techniques, and standards).
• Q—Quality: What does the symptom feel like? If patient cannot describe, offer probes such as “Is it sharp? Dull? Burning?”
• R—Radiate: Where is the symptom located? Is it in one place? Does it go anywhere else? Have patient be as precise as possible.
• S—Severity: Ask a patient to rate the severity of a symptom on a scale of 0 to 10. This gives you a baseline with which to compare in follow-up assessments.
• T—Time: Assesses onset and duration of symptom. When did it start? Does it come and go? If so, how often and for how long? What time of day or day of the week?
• Assessment is an important first step of the nursing process for learning as much as you can about each patient by partnering together in a therapeutic relationship.
• Assessment involves collecting information from a patient and secondary sources (e.g., health care providers, family members) along with interpreting and validating the information to form a complete database.
• Establishing a nurse-patient therapeutic relationship allows you to know a patient as a person.
• There are two approaches to gathering a comprehensive assessment: use of a structured database format and use of a problem-focused approach.
• Effectively communicating with patients during an assessment interview requires communication skills built on courtesy, comfort, connection, and confirmation.
• Once a patient provides subjective data, explore the findings further by collecting objective data.
• During assessment critically anticipate and use an appropriate branching set of questions or observations to collect data and cluster cues of assessment information to identify emerging patterns and problems.
• In a patient-centered interview an organized conversation with a patient allows the patient to set the initial focus and initiate discussion about his or her health problems.
• An initial patient-centered interview involves: (1) setting the stage, (2) gathering information about the patient’s problems and setting an agenda, (3) collecting the assessment or a nursing health history, and (4) terminating the interview.
• When literacy assessment tools are not available, a review of general cognitive ability and educational and/or occupational levels needs to be part of nursing assessment.
• An assessment needs to adapt to the unique needs of patients of backgrounds and cultures different from your own.
• When collecting a complete nursing history, let the patient’s story guide you in fully exploring the components related to his or her problems.
• Successful interpretation and validation of assessment data ensure that you have collected a complete database.
• Provides a precise definition of a patient’s responses to health problems that gives nurses and other members of the health care team a common language for understanding a patient’s needs
• Allows nurses to communicate (e.g., written and electronic) what they do among themselves with other health care professionals and the public
• Distinguishes the nurse’s role from that of other health care providers
• Helps nurses focus on the scope of nursing practice
• Fosters the development of nursing knowledge
• Promotes creation of practice guidelines that reflect the essence and science of nursing
To write a three-part nursing diagnosis, the acronym PES, which stands for problem, etiology, and symptoms, is helpful.
• P (problem)—NANDA-I label—Example: Impaired Physical Mobility
• E (etiology or related factor)—Example: incisional pain
• S (symptoms or defining characteristics)—Briefly lists defining characteristic(s) that show evidence of the health problem. Example: evidenced by restricted turning and positioning
Full three-part diagnostic statement: Impaired Physical Mobility related to incisional pain as evidenced by restricted turning and positioning.
• How has this health problem affected you and your family?
• What do you believe will help or fix the problem?
• What worries you the most about this problem?
• What do you expect from us, your nurses, to help maintain some of your values or practices for staying healthy?
• Which cultural practices do you observe to keep yourself and your family well?
2. Identify a NANDA-I diagnostic statement rather than the symptom. Identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom. One defining characteristic is insufficient for problem identification. For example, dyspnea alone does not definitively lead you to a diagnosis. However, the pattern of dyspnea, reduced chest excursion, and rapid respiratory rate are defining characteristics that lead you to the diagnosis of Ineffective Breathing Pattern. If a patient has severe chest pain resulting from a rib fracture, the final diagnosis will be Ineffective Breathing Pattern related to chest pain.
3. Identify a treatable related factor or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing intervention. An accurate related factor allows you to select nursing interventions directed toward correcting the etiology of the problem or minimizing a patient’s risk. A diagnostic test or a chronic dysfunction is not an etiology or a condition that a nursing intervention is able to treat. A patient with fractured ribs likely has pain when inhaling; impaired chest excursion; and slower, shallow respirations. An x-ray film may show atelectasis (collapse of alveolar air sacs) in the area affected. The nursing diagnosis of Ineffective Breathing Pattern related to shallow respirations is an incorrect diagnostic statement. Ineffective Breathing Pattern related to chest pain from rib fracture is more accurate.
4. Identify a problem caused by the treatment or diagnostic study rather than the treatment or study itself. Patients experience many responses to diagnostic tests and medical treatments. These responses are the area of nursing concern. The patient who has angina and is scheduled for a cardiac catheterization possibly has a nursing diagnosis of Anxiety related to lack of knowledge about cardiac testing. An incorrect diagnosis is Anxiety related to cardiac catheterization.
5. Identify a patient response to the equipment rather than the equipment itself. Patients are often unfamiliar with medical technology and its use. The diagnosis of Deficient Knowledge regarding the need for cardiac monitoring is accurate compared with the statement Anxiety related to cardiac monitor.
6. Identify a patient’s problems rather than your problems with nursing care. Nursing diagnoses are always patient centered and form the basis for goal-directed care. Consider a patient with a peripheral intravenous line. Potential Intravenous Complications related to poor vascular access indicates a nursing problem in initiating and maintaining intravenous therapy. The diagnosis Risk for Infection properly centers attention on the patient’s potential needs.
8. Identify a patient problem rather than the goal of care. You establish goals during the planning step of the nursing process. Goals based on accurate identification of a patient’s problems serve as a basis to determine problem resolution. Change the goal-phrased statement, “Patient needs high-protein diet related to potential alteration in nutrition,” to Imbalanced Nutrition: Less Than Body Requirements related to inadequate protein intake.
9. Make professional rather than prejudicial judgments. Base nursing diagnoses on subjective and objective patient data and do not include your personal beliefs and values. Remove your judgment from Impaired Skin Integrity related to poor hygiene habits by changing the nursing diagnosis to read Impaired Skin Integrity related to inadequate knowledge about perineal care.
10. Avoid legally inadvisable statements. Statements that imply blame, negligence, or malpractice have the potential to result in a lawsuit. The statement, “Acute Pain related to insufficient medication,” implies an inadequate prescription by a health care provider. Correct problem identification is Acute Pain related to poor adherence to analgesic schedule.
11. Identify the problem and etiology to avoid a circular statement. Circular statements are vague and give no direction to nursing care. Change the statement, “Impaired Breathing Pattern related to shallow breathing,” to identify the real patient problem and cause, Ineffective Breathing Pattern related to incisional pain.
12. Identify only one patient problem in the diagnostic statement. Every problem has different specific expected outcomes. Confusion during the planning step occurs when you include multiple problems in a nursing diagnosis. For example, Pain and Anxiety related to difficulty in ambulating are two nursing diagnoses combined in one diagnostic statement. A more accurate statement would be two separate diagnoses: Impaired Physical Mobility related to pain in right knee and Anxiety related to difficulty in ambulating. It is permissible to include multiple etiologies contributing to one patient problem, as in Complicated Grieving related to diagnosed terminal illness and change in family role.
• NANDA-I classifications are the most comprehensive.
• NANDA-I diagnoses are under continual refinement and development by professional nurses.
• Diagnostic conclusions include problems treated primarily by nurses (nursing diagnoses) and those requiring treatment by several disciplines (collaborative problems).
• Nurses manage collaborative problems by using medical, nursing, and allied health interventions.
• The use of standard formal nursing diagnostic statements provides a precise definition of a patient’s problem that gives nurses and other members of the health care team a common language for understanding a patient’s needs.
• Data analysis and interpretation involve recognizing patterns in clustered data, comparing them with standards such as the NANDA-I classification of nursing diagnoses and defining characteristics, and coming to a reasoned conclusion about a patient’s response to a health problem.
• Accurate diagnosis of patient problems ensures the selection of more effective and efficient nursing interventions.
• Defining characteristics are the subjective and objective clinical cues that a nurse gathers intentionally and unintentionally, clusters, and uses to form a diagnostic conclusion.
• When an assessment reveals defining characteristics that apply to more than one nursing diagnosis, gather more information to clarify your interpretation.
• Absence of defining characteristics suggests that you reject a proposed diagnosis.
• A problem-focused nursing diagnosis is usually written in a two-part format, including a diagnostic label and an etiological or related factor.
• A three-part diagnostic statement includes defining characteristics that apply to a patient’s condition.
• Assessing the cultural differences that affect how patients define health and illness and want or choose to be treated will assist in making correct diagnostic conclusions.
• The “related to” factor of a diagnostic statement helps you to individualize problem-focused and health promotion nursing diagnoses and provides direction for your selection of appropriate interventions.
• Risk factors serve as cues to indicate that a risk nursing diagnosis applies to a patient’s condition.
• A concept map is a visual representation of a patient’s nursing diagnoses and their relationship with one another.
• Nursing diagnostic errors occur by errors in data collection, interpretation and analysis of data, clustering of data, or the diagnostic statement.
• A correct goal statement: “Patient will ambulate independently in 3 days.”
• A correct outcome statement: “Patient ambulates in the hall 3 times a day by 4/22.”
• A common error is to write an intervention: “Ambulate patient in the hall 3 times a day.”
• What is the intervention, and is it evidence based?
• When should each intervention be implemented?
• How should the intervention be performed for this specific patient?
• Who should be involved in each aspect of intervention?
• Planning involves individualizing a plan of care for a patient’s unique needs.
• Priority setting is the ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing actions.
• Priorities help you anticipate and sequence nursing interventions when a patient has multiple nursing diagnoses and collaborative problems.
• A patient-centered goal or outcome reflects a patient’s specific behavior, not your own goals or interventions.
• The use of goals and outcomes in patient care is designed to focus the efforts of all health care team members on a common purpose.
• Outcomes provide the desired physiological, psychological, social, developmental, or spiritual responses that indicate resolution of a patient’s health problems.
• When writing goals and outcomes, use the SMART acronym: Specific, Measurable, Attainable, Realistic, and Timed.
• During planning select interventions designed to help a patient move from the present level of health to the level described in the goal and measured by the expected outcomes.
• Independent nursing interventions are actions that a nurse initiates without supervision or direction from others, are autonomous based on scientific rationale, and do not require an order from another health care provider.
• Health care provider-initiated interventions require specific nursing responsibilities and technical nursing knowledge.
• Care plans increase communication among nurses and facilitate the continuity of care from one nurse to another and from one health care setting to another.
• A nurse hand-off transfers essential information (along with responsibility and authority) from one nurse to the next during transitions in care and allows you to ask questions, clarify, and confirm important details.
• A concept map is a visual representation of a patient’s nursing diagnoses with links to nursing interventions, helping you learn to make better clinical decisions.
• The NIC taxonomy provides a standardization to help nurses select suitable interventions for patients’ problems.
• Correctly written nursing interventions include actions, frequency, quantity, method, and the person to perform them.
• Review all possible consequences associated with each possible nursing action (e.g., Tonya considers that the analgesic will relieve pain; have little or insufficient effect; or cause an adverse reaction, including sedating the patient and increasing the risk of falling).
• Determine the probability of all possible consequences (e.g., if Mr. Lawson’s pain continues to decrease with analgesia and positioning and there have been no side effects, it is unlikely that adverse reactions will occur, and the intervention will be successful; however, if the patient continues to remain highly anxious, his pain may not stay relieved, and Tonya needs to consider an alternative).
• Judge the value of the consequence to the patient (e.g., if the administration of an analgesic is effective, Mr. Lawson will likely become less anxious and more responsive to postoperative instruction and counseling about his anxiety).
1. Revise data in the assessment column to reflect the patient’s current status. Date any new data to inform other members of the health care team of the time that the change occurred.
2. Revise the nursing diagnoses. Delete nursing diagnoses that are no longer relevant and add and date any new diagnoses. Revise related factors and the patient’s goals, outcomes, and priorities. Date any revisions.
3. Revise specific interventions that correspond to the new nursing diagnoses and goals. Be sure that revisions reflect the patient’s present status.
4. Choose the method of evaluation for determining whether the patient achieved his or her outcomes.
1. Seek the information you need to be informed about a procedure. Check the scientific literature for evidence-based information, review resource manuals and the procedure book of the agency, or consult with experts (e.g., pharmacists, clinical nurse specialists).
2. Collect all equipment necessary for the procedure.
3. Have another nurse (e.g., staff nurse, faculty, clinical nurse specialist) who has completed the procedure correctly and safely provide assistance and guidance. Requesting assistance occurs frequently in all types of nursing practice. It is a learning process that continues throughout educational experiences and into professional development. One tip is to verbalize with an instructor or staff nurse the steps you will take before actually performing the procedure to improve your confidence and ensure accuracy.
• During this hospital stay did you get information in writing about which symptoms or health problems to look for after you left the hospital?
• Before giving you new medicine, how often did staff describe possible side effects in a way you could understand?
• Pairing—One RN works with a licensed practical nurse (LPN) and/or a NAP for a shift. The RN and LPN and/or NAP are not intentionally scheduled to work the same shift each day. For a given shift they work together, or are paired, and care for the same group of patients. Delegation usually increases with pairing.
• Partnering—Involves one RN and one LPN and/or NAP who are consistently scheduled to work together. The partners commit to healthy interpersonal relationships, trust in one another, and advance each other’s knowledge. It is recognized that the RN has the authority to make the delegation decisions.
• A direct care intervention is a treatment performed through interactions with a patient that include nurse-initiated, health care provider-initiated and collaborative approaches.
• Always think first and determine if an intervention is correct and appropriate and if you have the resources needed to implement it.
• Clinical guidelines or protocols are evidence-based documents that guide decisions and interventions for specific health care problems.
• Remaining competent and using good communication skills build your ability to participate in interdisciplinary practices.
• A clinical practice guideline establishes evidence-based interventions for specific health care problems or conditions.
• The implementation of nursing care often requires additional knowledge, nursing skills, and personnel resources.
• Before performing an intervention, make sure that a patient is as physically and psychologically comfortable as possible.
• Use good judgment during implementation to ensure that no nursing action is automatic.
• Know the purpose of each intervention, the associated preassessment and postassessment risks, steps in performing the intervention correctly, the current medical condition of a patient, and his or her expected response so you can anticipate what to expect in a given clinical situation and how to modify your approach.
• To anticipate and prevent complications, identify risks to a patient, adapt interventions to the situation, evaluate the relative benefit of a treatment versus the risk, and initiate risk-prevention measures.
• When you administer physical care techniques, protect yourself and the patient from injury, use proper infection control practices, stay organized, and follow applicable practice guidelines.
• When you delegate aspects of a patient’s care, you are responsible for ensuring that each task is assigned appropriately and completed according to the standard of care.
• Compare achieved effect with goals and expected outcomes.
• Recognize errors.
• Understand a patient situation, participate in self-reflection, and correct errors.
2. Evaluate a patient’s actual behavior or response.
3. Compare the established outcome criteria with the actual behavior or response.
4. Judge the degree of agreement between outcome criteria and the actual behavior or response.
5. If there is no agreement (or only partial agreement) between the outcome criteria and the actual behavior or response, what is/are the barrier(s)? Why did they not agree?
• During evaluation apply critical thinking to make clinical decisions and redirect nursing care to best meet patient needs.
• Positive evaluations occur when your patient meets desired outcomes and goals.
• Criterion-based standards for evaluation are the physiological, emotional, and behavioral responses that are a patient’s goals and expected outcomes.
• Evaluative measures are assessment skills or techniques that you use to collect data for determining if outcomes were met.
• It sometimes becomes necessary to collect evaluative measures over time to determine if a pattern of change exists.
• When interpreting findings, you compare a patient’s behavioral responses and the physiological signs and symptoms that you expect to see with those actually seen from your evaluation and judge the degree of agreement.
• Documentation of evaluative findings allows all members of the health care team to know whether or not a patient is progressing.
• A patient’s nursing diagnoses, priorities, and interventions sometimes change as a result of evaluation.
• Evaluation examines two factors: the appropriateness of the interventions selected and the correct application of the intervention.