Chapter 15
Critical Thinking in Nursing
Practice
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Critical Thinking Defined

Critical thinking is:


A continuous process characterized by openmindedness, continual inquiry, and perseverance,
combined with a willingness to look at each unique
patient situation and determine which identified
assumptions are true and relevant
Recognizing that an issue exists, analyzing
information, evaluating information, and making
conclusions
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Case Study


Carla is a third year nursing student assigned to a
surgical nursing unit. Mr. Javier Ramirez is a 55-yearold construction worker, admitted to the unit after
falling off scaffolding on a construction site.
His x-ray films revealed a right fractured femur and
right wrist fracture. An abdominal computed
tomography (CT) scan shows bruising of the liver. Mr.
Ramirez has not been hospitalized in the past. When
he first meets Carla, he is very quiet and asks few
questions.
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3
Clinical Decisions
in Nursing Practice
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

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Clinical decision making requires critical
thinking.
Clinical decision-making skills separate
professional nurses from technical and
ancillary staff.
Patients often have problems for which no
textbook answers exist.
Nurses need to seek knowledge, act quickly,
and make sound clinical decisions.
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4
Critical Thinking Skills
Interpretation
Analysis
Inference
Evaluation
Explanation
Self-regulation
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Thinking and Learning



Learning is a lifelong process.
Intellectual and emotional growth involves
learning new knowledge, as well as refining
the ability to think, solve problems, and make
judgments.
The science of nursing continues to grow.
Nurses need to be flexible and open to new
information.
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Case Study (cont’d)


Mr. Ramirez’s leg is in skeletal traction, and
his right arm is in a soft cast. Carla decides
that she needs to begin her care by
assessing Mr. Ramirez and determining his
health status.
She begins by reviewing his medical history.
She learns that he has a history of smoking
and was diagnosed with type 2 diabetes just
5 years ago.
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Concepts for a Critical Thinker

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Truth seeking
Open-mindedness
Analytic approach
Systematic approach
Self-confidence
Inquisitiveness
Maturity
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8
Critical Thinking Competencies
Scientific method
Problem solving
Decision making
Diagnostic
reasoning and
inference
Clinical decision
making
Nursing process as
a competency
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9
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10
Five Components
of Critical Thinking
Knowledge base
Experience
Nursing process
competencies
Attitudes
Standards
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11
Nursing Process

The nursing process is a five-step clinical
decision-making approach:
Assessment
Diagnosis
Planning
Implementation
Evaluation
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Case Study (cont’d)


Carla knows that Mr. Ramirez is likely to be in pain
because he is reluctant to move and take part in any
activity. Her options include conducting a thorough
pain assessment and learning how Mr. Ramirez feels
about his pain.
She must also be culturally sensitive and consider
how Mr. Ramirez’s Hispanic heritage may influence
his response to pain. Carla will then take what she
learns and use pain control therapies that Mr.
Ramirez will be likely to accept.
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13
Attitudes a Nurse Needs
Confidence
Independence
Fairness
Responsibility
Risk taking
Discipline
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14
Attitudes a Nurse Needs
Perseverance
Creativity
Curiosity
Integrity
Humility
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15
Case Study (cont’d)


When Carla notices that Mr. Ramirez is slow to
respond to her questions, grimaces when shifting
weight on his back, and is reluctant to have a
bed bath, her critical thinking leads to the
inference that Mr. Ramirez is in pain.
Carla decides to assess the situation more
thoroughly by asking Mr. Ramirez specific
questions about his comfort, such as, “Tell me if
you are hurting,” “Show me where the pain is
located,” and “Is this pain you have felt before?”
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Case Study (cont’d)


Before Carla begins her questions, she repositions
Mr. Ramirez to make him more comfortable. As she
does so, she observes an area of redness over his
left heel. Redness could be due to inflammation or
pressure on the skin. Carla palpates the area, noting
that it is tender to touch and warm.
She asks Mr. Ramirez if he has been moving his leg
much, and he says, “No, I haven’t. I am afraid I will
hurt my other leg.” These initial findings imply that
excess pressure is being applied to the heel.
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17
Quick Quiz!
1. The use of diagnostic reasoning involves a
rigorous approach to clinical practice and
demonstrates that critical thinking cannot be
done
A. Logically.
B. Haphazardly.
C. Independently.
D. In a vacuum.
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18
Case Study (cont’d)

Carla gently applies pressure to the area with her
finger and notes that after pressure is released, the
area does not blanch or turn white, a key sign of
excess pressure. She thinks about what she knows
about normal skin integrity, the effect of immobility,
and the effects of pressure on the skin. The
information she collects leads her to determine that
Mr. Ramirez has an early-stage pressure ulcer. The
nursing diagnosis would be “Impaired skin integrity.”
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Case Study (cont’d)


Carla continues to gently encourage Mr. Ramirez to
describe any symptoms or sensations that he is
experiencing. He tells Carla that he does have pain in
his stomach. Carla asks him to place his hand over
the area of discomfort. Mr. Ramirez places his hand
over the lower right quadrant of his abdomen.
On a scale of 0 to 10, Mr. Ramirez rates his pain at 7.
Carla inspects the area more closely and palpates
gently over the abdomen for the presence of
tenderness. She notes that the abdomen feels very
tight.
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20
Developing Critical Thinking Skills
Reflective Journaling:
A tool used to clarify concepts through
reflection by thinking back or recalling
situations
Concept Mapping:
A visual representation of patient problems and
interventions that illustrates an interrelationship
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Critical Thinking and Delegation
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
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Effective communication is needed between
registered nurses (RNs) and nursing assistive
personnel (NAP) for giving feedback and
clarifying tasks and patient status.
When patients’ clinical conditions change,
warranting attention by RNs, clear directions
are necessary to avoid missed care.
Applying critical thinking can help an RN
make the decision about when to
appropriately delegate care.
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22
Reflective Journaling
The Circle of Meaning
model adapted to
nursing encourages
concept clarification
and a search for
meaning in nursing
practice.
The Circle of Meaning
model uses a series
of questions to help
you through a clinical
experience and to
find meaning.
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23
Caring for Groups of Patients

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Identify the nursing diagnoses and collaborative
problems of each patient.
Decide which are most urgent.
Consider the time it will take to care for those
patients.
Consider the resources that you have to manage
each problem.
Consider how to involve the patients as participants
in care.
Decide how to combine activities.
Decide which nursing care procedures to delegate.
Discuss complex cases with the health care team.
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24
Meeting With Colleagues


When nurses have a formal means to discuss
their experiences such as a staff meeting or a
unit practice council, the dialogue allows for
questions, differing viewpoints, and sharing of
experiences.
When nurses are able to discuss their
practices, the process validates good practice
and offers challenges and constructive
criticism.
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25
Five-Step Nursing Process Model
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Components of Critical Thinking in
Nursing
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I. Specific knowledge base in nursing
II. Experience
III. Critical thinking competencies
IV. Attitudes for critical thinking
V. Standards for critical thinking


A. Intellectual standards
B. Professional standards
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27
Quick Quiz!
2. The nursing process organizes your
approach while delivering nursing care. To
provide the best professional care to patients,
nurses need to incorporate nursing process
and
A. Decision making.
B. Problem solving.
C. Intellectual standards.
D. Critical thinking skills.
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28
Synthesis of Critical Thinking With
the Nursing Process Competency
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29
Case Study (cont’d)


Carla does what she can to position Mr.
Ramirez more comfortably and makes sure
his leg discomfort is under control. She knows
that the increased pain and tightness he is
experiencing suggest that something is
causing pressure in the abdomen.
It could mean the patient is having bleeding
from his bruised liver. Carla decides to call
Mr. Ramirez’s physician immediately.
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30
Critical Thinking Synthesis
A reasoning process used to reflect on and
analyze thoughts, actions, and knowledge
Requires a desire
to grow intellectually
Requires the use of nursing process
to make nursing care decisions
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31
Chapter 16
Nursing Assessment
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Five-Step Nursing Process
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33
Nursing Process




The nursing process is a variation of scientific
reasoning.
Practicing the five steps of the nursing process allows
you to be organized and to conduct your practice in a
systematic way.
You learn to make inferences about the meaning of a
patient’s response to a health problem or generalize
about the patient’s functional state of health.
Through assessment, a pattern begins to form.
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34
Critical Thinking Approach
to Assessment


Assessment involves collecting information
from the patient and from secondary sources
(e.g., family members), along with interpreting
and validating the information to form a
complete database.
Two stages of assessment:


Collection and verification of data
Analysis of data
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35
Case Study


Ms. Carla Thompkins is being admitted to the
medical-surgical unit as a postop patient. Ms.
Thompkins, a 52-year-old schoolteacher, is
recovering from a below-the-knee amputation (BKA)
secondary to complications of type 2 diabetes.
Ms. Thompkins is admitted to the unit not only so her
recovery from the BKA may be monitored, but also
because Ms. Thompkins is going to receive
preliminary occupational and physical therapy to help
her adapt to the amputation.
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Database


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The purpose of assessment is to establish a
database about the patient’s perceived
needs, health problems, and responses to
these problems.
In addition, the data reveal related goals,
experiences, health practices, values, and
expectations about the health care system.
Critical thinking skills help you to synthesize
relevant information and use it in a purposeful
way.
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37
Data Collection
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Sources of data
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Patient (interview, observation, physical
examination)—the best source of information
Family and significant others (obtain patient’s
agreement first)
Health care team
Medical records
Scientific literature
Nurse’s experience
Subjective vs. objective data
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Cues and Inferences
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39
Comprehensive Assessment
Approaches

Use of a structured database format, based
on an accepted theoretical framework or
practice standard



Example: Gordon’s model of functional health
patterns
Problem-oriented approach
Assessment moves from general to specific.
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Process of Assessment





Collect data.
Cluster cues, make inferences, and identify
patterns and problem areas.
Critically anticipate.
Be sure to have supporting cues before
making an inference.
Knowing how to probe and frame questions is
a skill that grows with experience.
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41
Methods of Data Collection

Patient-centered interview = An organized
conversation with the patient
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


Set the stage (preparation, environment, greeting).
Set an agenda/gather information about patient’s
concerns.
Collect the assessment or nursing health history;
assure the patient of confidentiality.
Terminate the interview (cue the end).
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Interview Techniques
Open-ended vs. closed-ended questions
 Back-channeling
 Probing
------------------------------------------ Because a patient’s report includes subjective
information, validate data from the interview
later with objective data.
 Obtain information (as appropriate) about a
patient’s physical, developmental, emotional,
intellectual, social, and spiritual dimensions.

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43
Case Study (cont’d)

During the assessment, Ms. Thompkins
complains of pain at the incision site.

Ms. Thompkins’ report of pain is an example of
what type of data?
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44
Cultural Considerations
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

To conduct an accurate and complete
assessment, you need to consider a patient’s
cultural background.
When cultural differences exist between you
and a patient, respect the unfamiliar and be
sensitive to a patient’s uniqueness.
If you are unsure about what a patient is
saying, ask for clarification to prevent making
the wrong diagnostic conclusion.
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45
Quick Quiz!
1. A patient is admitted to the hospital with
shortness of breath. As the nurse assesses this
patient, the nurse is using the process of
A. Evaluation.
B. Data collection.
C. Problem identification.
D. Testing a hypothesis.
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46
Nursing Health History
Biographical
information
Reason for seeking
health care
Health history
Patient expectations
Environmental history
Spiritual health
Psychosocial history
Review of systems
Present illness or
health concerns
Family history
Documentation of findings
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Next Assessment Steps
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Physical examination = An investigation of
the body to determine its state of health
Observation of patient behavior (verbal vs.
nonverbal)
Diagnostic and laboratory data
Interpreting and validating assessment data.
Validation of assessment data consists of
comparison of data with another source to
determine accuracy of the data.
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Case Study (cont’d)
Which of the following statements or questions made
by Yolanda to Ms. Thompkins addresses the nature
of Ms. Thompkins’ pain?
(Select all that apply.)
A. “Describe your pain to me.”
B. “Is the pain worse in the morning or in the
evening?”
C. “Place your hand over the area that is
uncomfortable.”
D. “Rate your pain on a scale of 0 to 10.”

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49
Data Documentation
The last component of a complete
assessment
Legal and professional
responsibility
Requires accurate and approved
terminology and abbreviations
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50
Quick Quiz!
2. The nursing process organizes your
approach to delivering nursing care. To
provide care to your patients, you will need to
incorporate nursing process and
A. Decision making.
B. Problem solving.
C. Interview process.
D. Intellectual standards.
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51
Case Study (cont’d)

True or False: Yolanda knows that the best
source of information regarding Ms.
Thompkins’ care is the surgeon.
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Concept Mapping
A visual representation that allows
nurses to graphically illustrate the
connections between a patient’s
health problems
Allows nurses to obtain a holistic
perspective of health care needs
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53
Chapter 17
Nursing Diagnosis
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Nursing Diagnosis
1. Medical
diagnosis
Identification of a disease
condition based on specific
evaluation of signs and symptoms
2. Nursing
diagnosis
Clinical judgment about the
patient in response to an actual or
potential health problem
3. Collaborative
problem
Actual or potential physiological
complication that nurses monitor
to detect a change in patient
status
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55
History of Nursing Diagnosis

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First introduced in 1950
In 1953, Fry proposed the formulation of a
nursing diagnosis.
In 1973, the first national conference was
held.
In 1980 and 1995, the American Nurses
Association (ANA) included diagnosis as a
separate activity in its publication Nursing: a
Social Policy Statement.
In 1982, NANDA was founded.
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Case Study


John is a first semester nursing student who is
particularly interested in the cardiac system and
specifically heart disease since his father died of a
heart attack at age 48. John decided to go into
nursing because of his father’s death, which
prompted him to select a career that improves
people’s lives.
John is studying nursing diagnoses in his nursing
fundamentals course and is learning the steps of the
nursing diagnostic process. He knows this
information will help him care for cardiac patients in
the future.
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Nursing Diagnostic Process
Assessment of patient’s health status:
• Patient, family, and health care resources
constitute database.
• Nurse clarifies inconsistent or unclear
information.
• Critical thinking guides and directs line of
questioning and examination to reveal detailed
and relevant database.
Validate data with other sources.
Are additional data needed? If so, reassess.
If not, continue…
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Nursing Diagnostic Process
(cont’d)
If no additional data are needed, proceed:
Interpret and analyze meaning of data
Data clustering
• Group signs and symptoms.
• Classify and organize.
Look for defining characteristics
and related factors.
Identify patient needs.
Formulate nursing diagnoses
and collaborative problems.
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Nursing Diagnostic Statements
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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
patients’ needs
Allows nurses to communicate what they do among
themselves and with other health care professionals
and the public
Distinguishes the nurse’s role from that of the
physician or other health care provider
Helps nurses focus on the scope of nursing practice
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Case Study (cont’d)

John reviews the phases of the nursing
process.

Rank in correct order the phases of the nursing
process:
• Evaluation
• Planning
• Assessment
• Diagnosis
• Implementation
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Critical Thinking and the
Nursing Diagnostic Process


The diagnostic reasoning process involves
using the assessment data you gather about
a patient to logically explain a clinical
judgment or a nursing diagnosis.
Nursing diagnoses and definitions



Defining characteristics = Clinical criteria or
assessment findings
Related factors pertinent to the diagnoses
Interventions suited for treating the diagnoses
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Data Clustering



A data cluster is a set of signs or symptoms
gathered during assessment that you group
together in a logical way.
Data clusters are patterns of data that contain
defining characteristics—clinical criteria
that are observable and verifiable.
Each clinical criterion is an objective or
subjective sign, symptom, or risk factor that,
when analyzed with other criteria, leads to a
diagnostic conclusion.
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Case Study (cont’d)

Because of John’s interest in cardiac nursing,
he is familiar with the clinical criteria for heart
disease.

Which of the following is an example of a clinical
criterion?
(Select all that apply.)
• Hypertension
• Fatigue
• Food preference
• High cholesterol
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Interpretation—
Identifying Health Problems
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It is critical to select the correct diagnostic label for a
patient’s need.
From assessment to diagnosis, move from general
information to specific.
Think of the problem identification phase in
assessment as the general health care problem
and the formulation of the nursing diagnosis as the
specific health problem.
The absence of certain defining characteristics
suggests that you reject a diagnosis under
consideration.
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Formulating a Nursing Diagnosis



A related factor is a condition, historical factor, or
causative event that gives a context for the defining
characteristics and shows a type of relationship with
the nursing diagnosis.
A related factor allows you to individualize a nursing
diagnosis for a specific patient.
When you are ready to form a plan of care and select
nursing interventions, a concise nursing diagnosis
allows you to select suitable therapies.
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Types of Nursing Diagnoses
Actual Nursing Describes human responses
Diagnosis
to health conditions or life
processes
Risk Nursing
Diagnosis
Health
Promotion
Nursing
Diagnosis
Describes human responses to
health conditions/life processes
that may develop
A clinical judgment of
motivation, desire, and
readiness to enhance well-being
and actualize human health
potential
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Components of a Nursing Diagnosis
Diagnostic Label (NANDA-I) Definition
Related Factors/Etiology:
Treatment-related
Pathophysiological (biological or psychological)
Maturational
Situational (environmental or personal)
PES Format:
Problem
Etiology
Symptoms (or defining characteristics)
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Case Study (cont’d)

John learns the four types of nursing
diagnoses.

Which of the following are the four types of
nursing diagnoses?
(Select all that apply.)
• Actual diagnoses
• Risk diagnoses
• Wellness diagnoses
• Health promotion diagnoses
• Disease prevention diagnoses
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Cultural Relevance of
Nursing Diagnoses

Consider patients’ cultural diversity when
selecting a nursing diagnosis. Ask questions
such as:





How has this health problem affected you and
your family?
What do you believe will help or fix the problem?
What worries you most about the problem?
Which practices within your culture are important
to you?
Cultural awareness and sensitivity improve
your accuracy in making nursing diagnoses.
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Case Study (cont’d)

John knows that a ______________
diagnosis is applied to vulnerable
populations.
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Concept Mapping
Nursing Diagnosis
A visual representation of a patient’s
nursing diagnoses and their relationships
with one another
Concept maps promote problem solving and
critical thinking skills by
organizing complex patient data,
analyzing concept relationships, and
identifying interventions.
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Sources of Diagnostic Error
Data collection
Data clustering
Interpretation and analysis of data
Labeling the diagnosis/
the diagnostic statement
Documentation and informatics
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73
Quick Quiz!
1. Concept mapping is one way to
A. Connect concepts to a central subject.
B. Relate ideas to patient health problems.
C. Challenge a nurse’s thinking about patient
needs and problems.
D. Graphically display ideas by organizing data.
E. All of the above
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Diagnostic Statement Guidelines
1. Identify the patient’s response, not the medical
diagnosis.
2. Identify a NANDA-I diagnostic statement rather
than the symptom.
3. Identify a treatable cause or risk factor rather than
a clinical sign or chronic problem that is not
treatable through nursing intervention.
4. Identify the problem caused by the treatment or
diagnostic study rather than the treatment or study
itself.
5. Identify the patient response to the equipment
rather than the equipment itself.
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Diagnostic Statement Guidelines
(cont’d)
6. Identify the patient’s problems rather than your
problems with nursing care.
7. Identify the patient problem rather than the nursing
intervention.
8. Identify the patient problem rather than the goal of care.
9. Make professional rather than prejudicial judgments.
10. Avoid legally inadvisable statements.
11. Identify the problem and its cause to avoid a circular
statement.
12. Identify only one patient problem in the diagnostic
statement.
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Quick Quiz!
2. For a student to avoid a data collection error, the
student should
A. Assess the patient and, if unsure of the finding, ask a
faculty member to assess the patient.
B. Review his or her own comfort level and competency
with assessment skills.
C. Ask another student to perform the assessment.
D. Consider whether the diagnosis should be actual,
potential, or risk.
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Nursing Diagnosis:
Application to Care Planning


By learning to make accurate nursing
diagnoses, your care plan will help
communicate the patient’s health care
problems to other professionals.
A nursing diagnosis will ensure that you
select relevant and appropriate nursing
interventions.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Chapter 18
Planning Nursing Care
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Establishing Priorities



Ordering of nursing diagnoses or patient
problems uses determinations of urgency
and/or importance to establish a preferential
order for nursing actions.
Helps nurses anticipate and sequence
nursing interventions
Classification of priorities:



High—Emergent
Intermediate
Low—Affect patients’ future well-being
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Establishing Priorities (cont’d)




The order of priorities changes as a patient’s
condition changes.
Priority setting begins at a holistic level when
you identify and prioritize a patient’s main
diagnoses or problems.
Patient-centered care requires you to know a
patient’s preferences, values, and expressed
needs.
Ethical care is a part of priority setting.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Priorities in Practice
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Case Study


Fulmala is a first semester nursing student
who is assigned to Ms. Nadine Skyfall, a 35
y/o American Indian patient diagnosed with
severe anemia secondary to a bleeding
peptic ulcer. Ms. Skyfall experiences pain
because of the ulcer and weakness and
fatigue resulting from the anemia.
Fulmala develops Ms. Skyfall’s plan of care,
which addresses pain, weakness, and
fatigue. Fulmala includes nutrition and patient
safety as part of the plan of care.
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Critical Thinking in Setting Goals and
Expected Outcomes

Goal



A broad statement that describes the desired
change in a patient’s condition or behavior
An aim, intent, or end
Expected outcome

Measurable criteria to evaluate goal achievement
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Goals of Care
Patient-centered goal:
A specific and measurable behavior or
response that reflects a patient’s highest
possible level of wellness and independence
in function
Short-term goal:
An objective behavior or response expected
within hours to a week
Long-term goal:
An objective behavior or response expected
within days, weeks, or months
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Goals of Care (cont’d)
Always partner with patients when setting
their individualized goals.
For patients to participate in goal setting, they
need to be alert and must have some degree of
independence in completing activities of daily
living, problem solving, and decision making.
Patients need to understand and see the value
of nursing therapies, even though they are often
totally dependent on you as the nurse.
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Expected Outcomes






An objective criterion for goal achievement
A specific, measurable change in a patient’s
status that you expect in response to nursing
care
Direct nursing care
Determine when a specific, patient-centered
goal has been met
Are written sequentially, with time frames
Usually, several are developed for each
nursing diagnosis and goal.
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Nursing Outcomes Classification



A nursing-sensitive patient outcome is a
measurable patient, family, or community state,
behavior, or perception largely influenced by and
sensitive to nursing interventions.
The Iowa Intervention Project published the Nursing
Outcomes Classification (NOC) and linked the
outcomes to NANDA International nursing diagnoses.
NOC outcomes provide a common nursing language
for continuity of care and measuring the success of
nursing interventions.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Seven Guidelines for Writing Goals
Patient centered
Singular goal or
outcome
Observable
Measurable
Time limited
Mutual factors
Realistic
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Quick Quiz!
1. A patient is suffering from shortness of
breath. The correct goal statement would be
written as
A. The patient will be comfortable by the
morning.
B. The patient will breath unlabored at 14 to 18
breaths per minute by the end of the shift.
C. The patient will not complain of breathing
problems within the next 8 hours.
D. The patient will have a respiratory rate of 14
to 18 breaths per minute.
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Critical Thinking in Planning Care


Nursing interventions are treatments or
actions based on clinical judgment and
knowledge that nurses perform to meet
patient outcomes.
Nurses need to:



Know the scientific rationale for the intervention
Possess the necessary psychomotor and
interpersonal skills
Be able to function within a setting to use health
care resources effectively
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Types of Interventions

Nurse initiated


Physician initiated


Independent—Actions that a nurse initiates
Dependent—Require an order from a physician or
other health care professional
Collaborative

Interdependent—Require combined knowledge,
skill, and expertise of multiple health care
professionals
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Clarifying an Order


When preparing for physician-initiated or
collaborative interventions, do not
automatically implement the therapy, but
determine whether it is appropriate for the
patient.
The ability to recognize incorrect therapies is
particularly important when administering
medications or implementing procedures.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)

Fulmala develops Ms. Skyfall’s plan of care,
including writing the goals and expected
outcomes.

Fulmala knows that the guidelines for writing goals
and expected outcomes include which of the
following?
(Select all that apply.)
A. Measurable
B. Time-limited
C. Observable
D. Diagnostic
E. Realistic
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Selection of Interventions

Six factors to consider:
Characteristics of nursing diagnosis
Goals and expected outcomes
Evidence base for interventions
Feasibility of the interventions
Acceptability to the patient
Nurse’s competency
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Nursing Interventions Classification
(NIC)



The Iowa Intervention Project developed a
set of nursing interventions that provides a
level of standardization to enhance
communication of nursing care across health
care settings and to compare outcomes.
The NIC model includes three levels:
domains, classes, and interventions for ease
of use.
NIC interventions are linked with NANDA
International nursing diagnoses.
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Case Study (cont’d)

Fulmala knows that _________________
interventions require an order from a
physician or another health care professional.
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Systems for Planning Nursing Care

Nursing care plan = Nursing diagnoses, goals
and expected outcomes, and nursing
interventions, and a section for evaluation
findings so any nurse is able to quickly
identify a patient’s clinical needs and situation



Reduces the risk for incomplete, incorrect, or
inaccurate care
Changes as the patient’s problems and status
change
Interdisciplinary care plan = Contributions
from all disciplines involved in patient care.
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Change of Shift



A critical time, when nurses collaborate and share
important information that ensures the continuity of
care for a patient and prevents errors or delays in
providing nursing interventions
Change-of-shift report: Communicates information
from offgoing to oncoming patient care personnel =
“Nurse handoff”
Focus your reports on the nursing care, treatments,
and expected outcomes documented in the care
plans.
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Student Care Plans

A student care plan



Helps you apply knowledge gained from the
nursing and medical literature and the classroom
to a practice situation
Is more elaborate than a care plan used in a
hospital or community agency because its
purpose is to teach the process of planning care
Planning care for patients in communitybased settings involves


Educating the patient/family about care
Guiding them to assume more of the care over
time
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Critical Pathways


Critical pathways are patient care plans that
provide the multidisciplinary health care team
with activities and tasks to be put into practice
sequentially.
The main purpose of critical pathways is to
deliver timely care at each phase of the care
process for a specific type of patient.
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Concept Maps



Provide a visually graphic way to show the
relationship between patients’ nursing
diagnoses and interventions
Group and categorize nursing concepts to
give you a holistic view of your patient’s
health care needs and help you make better
clinical decisions in planning care
Help you learn the interrelationships among
nursing diagnoses to create a unique
meaning and organization of information
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Case Study (cont’d)
What are some examples of independent
nursing interventions that Fulmala may
develop for Ms. Skyfall?
(Select all that apply.)
A. Medication administration
B. Medication teaching
C. Patient positioning
D. Family teaching

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Quick Quiz!
2. When caring for a patient who has multiple
health problems and related medical
diagnoses, nurses can best perform nursing
diagnoses and nursing interventions by
developing a
A. Critical pathway.
B. Nursing care plan.
C. Concept map.
D. Diagnostic label.
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Consulting Other Health Care
Professionals



Planning involves consultation with members of the
health care team.
Consultation is a process by which you seek the
expertise of a specialist such as your nursing
instructor, a physician, or a clinical nurse educator to
identify ways to handle problems in patient
management or in planning and implementation of
therapies.
Consultation occurs at any step in the nursing
process, most often during planning and
implementation.
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When and How to Consult

When: The exact problem remains unclear
How: Begin with your understanding of the patient’s
clinical problem.
Direct the consultation to the right professional.
Provide the consultant with relevant information
about the problem area: Summary, methods used to
date, and outcomes
Do not influence consultants.
Be available to discuss the consultant’s findings.
Incorporate the suggestions.
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Case Study (cont’d)

Fumala works with the nutritionist to develop
a meal plan for Ms. Skyfall.

True or False: Collaborative interventions are
therapies that involve multiple health care
professionals.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Quick Quiz!
3. Consultation occurs most often during which
phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
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