LOGIC AND CRITICAL THINKING by Kate Piedad

1st Year, Summer: Finals AY 2022-2023

PLANNING
THE NURSING PROCESS: CLINICAL JUDGMENT ● Plan of care, goals, interventions, and desired outcomes
● The nursing process is the essential core of practice for the registered nurse
to deliver holistic, patient-focused care ● Goals and outcomes
● The utilization of the nursing process to guide care is clinically significant ○ Directly impact patient care based on evidence-based practice
going forward in this dynamic, complex world of patient care. guidelines
● The nursing process is a five-step systematic approach that allows you to ● Patient-specific goals and attainment assist in ensuring a positive outcome
provide individualized care to a client. ● Nursing care plans:
○ Essential in this phase of goal setting
STEPS OF THE NURSING PROCESS ○ Provide a course of direction for personalized care tailored to an
ASSESSMENT individual’s unique needs
● Gather information about the client’s condition
● Subjective data
○ Verbal statements from the patient or caregiver ● SMART goals
● Objective data ○ Specific
○ Measurable, tangible data (vital signs, intake and output, height and ○ Measurable or meaningful
weight) ○ Attainable or action-oriented
● Data may come from the patient directly or from primary caregivers who may ○ Realistic or results-oriented
or may not be direct relation family members. ○ Timely or time-oriented
● Electronic health records
○ Populate data in and assist in assessment IMPLEMENTATION
● Perform the identified nursing interventions
DIAGNOSIS ● Implemented according to the care plan, continuity of care for the patient
● Also known as analysis during hospitalization and in preparation for discharge
● Identify the client’s problems ● Involves action and the actual carrying out of nursing interventions outlined
● Formulation of a nursing diagnosis: assists in planning and implementation in the plan of care
of patient care ● Requires nursing interventions
● The North American nursing diagnosis association (NANDA): up to date list ○ Applying a cardiac monitor or oxygen, direct or indirect care,
of nursing diagnoses medication administration, and standard treatment protocols
● Clinical judgment about responses to actual or potential health problems on ● Documentation in the patient’s record
the part of the patient, family or community
● Maslow's Hierarchy of Needs EVALUATION
○ Helps to prioritize and plan care based on patient centered outcomes ● Determine if the goals and desired outcomes were met
● Vital to a positive patient outcome
● Whenever a healthcare provider intervenes or implements care, they must
reassess or evaluate to ensure the desired outcome has been met.
● Frequent reassessment depending upon overall patient condition
● Adoption of plan of care based on new assessment data
 IN A NUTSHELL SECONDARY SOURCE
● Assessment includes both subjective and objective data. ● Healthcare team
● A nursing diagnosis assists in the planning and implementation of patient ● Medical records
care. ● Scientific literature
● Patient-specific goals and attainment assist in ensuring a positive outcome.
Goals should be created using the SMART format. DATA COLLECTION
● Implementation involves action and the actual carrying out of nursing ● Subjective data - Symptoms; What you are told
interventions outlined in the plan of care. ● Objective data - Signs; What you can see or validate (measurable)
● Whenever a healthcare provider intervenes or implements care, they must ● Example situations:
reassess or evaluate to ensure the desired outcome has been met. ○ Pain
■ Client states: “I am having very bad pain in my leg.”
■ Nurse sees the client limping and grimacing when walking.
ASSESS ○ Fever
● In the assessment process, the nurse will gather information to identify ■ Mother states: “My child has a fever.”
health problems that contribute to the patient’s overall health and well-being. ■ The client’s temperature is 38.4°C

CRITICAL THINKING APPROACH TO ASSESSMENT PROCESS OF ASSESSMENT

● Two stages of assessment: ● Collect data.
● Collection and verification of information ● Cluster information and identify similarities.
● Primary source: client ● Collect more information as needed to form a complete clinical picture.
● Secondary source: family, healthcare providers, medical records ● Be sure to have supporting cues before making an inference.
● Analysis of information
● Understanding and processing the information within the context of the
patient’s clinical condition ASSESSMENT APPROACHES
● Health history
○ Gathering information that may help you better understand the patient’s
DATABASE
current health problems
PURPOSE OF ASSESSMENT RESULTS OF DATABASE ● Head-to-toe physical assessment
● Perceived needs ● Form a plan of care ○ Using assessment skills to recognize abnormalities
● Identify health concerns ● Prioritize problems ● Focused assessment
● Identify primary problems ● Focus on patient needs ○ Looking closely at a particular area of concern

Critical thinking skills help you to synthesize relevant information and use it in a METHODS OF INFORMATION COLLECTION
purposeful way. ● Client-centered interview = an organized conversation with the client
○ Set the stage.
SOURCES OF DATA ○ Set an agenda.
PRIMARY SOURCE ○ Collect the assessment or nursing health history
● Client (interview, observation, physical examination) the best source of ○ Terminate the interview.
information
● Family and significant others (obtain client’s agreement first)
● Vital signs and diagnostics

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INTERVIEW TECHNIQUES ● A strong knowledge of interviewing techniques is essential for nurses to be
able to have respectful, informed conversations about a client’s health
● Ask open-ended questions
● Ask clarifying questions
● Validate information DIAGNOSE
● Allow the patient to talk without too many interruptions
● Be respectful of cultural and behavioral differences TYPES OF DIAGNOSIS
● Differentiate between subjective vs. objective information ● MEDICAL DIAGNOSIS
○ Identification of a disease condition based on specific information
NEXT ASSESSMENT STEPS gained from diagnostic evaluations
● Physical examination ● NURSING DIAGNOSIS
○ Involves techniques of inspection, palpation, percussion, ○ Identification of a health risk or alteration in a body system for which
auscultation, and smell interventions and outcomes can be selected to correct the problem(s)
○ Helps collect valuable objective information ● COLLABORATIVE PROBLEM
● Observation of client behavior (verbal vs. nonverbal) ○ Both providers implement interventions based on the diagnoses, such
○ Gather additional objective information as placing orders and administering treatments, and evaluate
○ Watch client’s level of function: physical, developmental, outcomes or progress
psychological, and social aspects of everyday living
● Diagnostic information WHY NURSING DIAGNOSES?
○ Provides you with information needed to develop a plan of care ● Nursing diagnoses allow nurses to practice independently within their scope
○ Might include: laboratory values, imaging, focused assessments of practice. The North American Nursing Diagnosis Association (NANDA)
(example: cognitive evaluation) has developed, refined, and promoted nursing diagnoses for use by all
● Interpreting and validating assessment data professional nurses.
○ Helps when selecting a nursing diagnosis ● Purpose of the nursing diagnosis:
○ Recognize patterns or trends in the clustered data and compare ○ Provides precise definition of client’s problems
them with standards ○ Allows licensed nurses and other members of the healthcare team to
utilize or communicate with a common language of understanding the
DATA DOCUMENTATION client needs
● It is the professional responsibility of the nurse to ensure that care gets ○ Provides guidance for developing nursing interventions
documented.
● The client record is a legal document. NURSING DIAGNOSIS PROCESS
● Use accurate and approved terminology. ● Assessment, validation, and interpretation of the client’s health status
● This must be completed in a timely manner. ● Information clustering and identification of defining characteristics
● Identification of client needs
IN A NUTSHEL… ● Formulation of nursing diagnosis and collaborative problems
● The assessment is a multi-step process that requires the application of
critical thinking. NURSING DIAGNOSIS STATEMENTS
● Information can be both subjective or objective.
● Provide a precise definition of a client’s problem, allowing nurses and other
● A client-centered interview, such as a health history, is an organized
members of the healthcare team to utilize or communicate with a common
conversation with the client with the intent of gathering more information.
language for understanding client’s needs

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 ● Allow nurses to communicate what they do among themselves, with other ● HEALTH PROMOTION NURSING DIAGNOSIS
health care professionals. ○ A clinical judgment of an individual’s motivation desire, and readiness
● Distinguish the nurse’s role from that of the physician or other healthcare to enhance well-being: a person’s readiness is supported by defining
providers. characteristics
● Help nurses focus on the scope of nursing practice. ○ Example: Readiness for enhanced medication compliance

USING CRITICAL THINKING COMPONENTS OF NURSING DIAGNOSIS

● Diagnostic process ● Nursing diagnosis
○ Information clustering ○ NANDA approved nursing diagnosis describing the client’s response to
○ Identifying client’s health problems a problem
○ Formulating diagnosis ● Related factor
○ A reason or factor that caused the problem identified in the diagnosis
DATA CLUSTERING ● As evidenced by (signs and symptoms)
● Bringing together information in a logical way to form patterns with defining ○ Objective or subjective information
characteristics
○ Information gathered in an assessment Nursing diagnosis + Related factor + As evidenced by (signs and symptoms)
○ Clustered information that leads to a nursing diagnosis = Individualized to a specific client
Example:Impaired skin integrity + Related to abdominal surgery + As evidenced by
INTERPRETATION - IDENTIFYING HEALTH PROBLEMS a 4×4 cm abdominal incision = Individualized to a specific client
● Assessment information
○ Subjective and objective information, health history, chief complaint, CONSIDERING CULTURE
diagnostics ● Consider clients cultural diversity when selecting a nursing diagnosis. Ask
● General information questions such as:
○ Problem identification ○ How has this health problem affected you and your family?
● Specific information ○ What do you believe will help or fix the problem?
○ Formulation of nursing diagnosis ○ What worries you most about the problem?
● A nursing diagnosis can be accepted based on the presence of certain ○ Which practices within your culture are important to you?
information, or rejected based on the absence of certain information. ● Cultural awareness and sensitivity improve your accuracy in making nursing
diagnoses.
TYPES OF NURSING DIAGNOSIS
● ACTUAL NURSING DIAGNOSIS SOURCES OF DIAGNOSTIC ERROR
○ Describes human responses to health conditions or life processes: ● Assessment, validation, and interpretation of the health status
assessment data are sufficient to establish the nursing diagnosis ○ Avoid errors by collecting information in an organized manner and
○ Example: Impaired skin integrity validating information.
● RISK FOR NURSING DIAGNOSIS ○ It is not always possible to collect data in an organized way in real time.
○ Describes human responses to health conditions/life processes that You can go back to reorganize and validate assessment data anytime.
may develop: do not have defining characteristics because they have ● Information clustering and identification of defining characteristics
not occurred yet ○ Errors in data collection occur when data are clustered prematurely,
○ Example: Risk for infection, Risk for falls incorrectly, or not at all.
● Identification of client needs

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 ● Formulation of nursing diagnosis and collaborative problems ○ INTERMEDIATE
○ Word the diagnostic statement in appropriate, concise, and precise ■ Non-emergent or nonlife-sustaining needs
language using NANDA terminology. ■ Pain
■ Nutrition
DIAGNOSTIC STATEMENT GUIDELINES ○ LOW
■ Long-term health needs that address the future
■ Rehabilitation
■ Disease specific education
■ Health maintenance and prevention

PRIORITIES IN PRACTICE
● Identify a treatable cause or risk factor rather than a clinical sign or chronic
problem that is not treatable.
● Identify priority problems.
● Identify only one client’s problem in each diagnostic statement.

IN A NUTSHELL…
● By learning to make accurate nursing diagnoses, you will help communicate
the client’s healthcare problems to other professionals.
● A nursing diagnosis will ensure that you select relevant and appropriate
nursing interventions and contribute to continuity of care.

PLAN
ESTABLISHING PRIORITIES
● Prioritizing diagnoses helps establish a sequence for nursing interventions
○ HIGH EMERGENT
■ If untreated, will result in harm SMART GOALS
■ Airway ● Once the nursing diagnosis is selected, specific goals need to be set to
■ Oxygenation address each diagnosis.
■ Circulation ● Specific, Measureable, Attainable, Realistic, Timely

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 ● Example: TYPES OF INTERVENTIONS
○ Scenario: Mrs. Smith is having severe pain in her right leg that is
● NURSE INITIATED
limiting her mobility
○ Independent: actions that a nurse initiates
○ Goal: Mrs. Smith’s pain will be controlled to a reported score of 5 or
○ Example: encourage client to walk 100 ft three times daily
less by the end of shift
○ Ambulate client
● PHYSICIAN INITIATED
GOALS OF CARE ○ Dependent: require an order from a healthcare professional
● Client-centered: reflect the client’s highest level of wellness and function ○ Example: give PRN blood pressure medicine when systolic blood
○ Hours - Short Term - Week pressure is greater than 160 mm Hg
○ Days - Long Term - Months ○ Giving medications as ordered
● Always partner with clients when setting their individualized goals. ● COLLABORATIVE
○ Able to participate in activities of daily living (ADLs) ○ Interdependent: require combined knowledge, skill, and expertise of
○ Able to participate in problem-solving multiple healthcare professionals
○ Able to participate in decision-making ○ Example: encourage food consistent with dietary needs as specified by
○ Able to understand the value of nursing therapies the dietician
○ Diet or therapies
EXPECTED OUTCOMES
● Each goal will have at least one expected outcome that defines how the goal NANDA, NOC, & NIC
will be met. ● A nursing plan of care is an important part of providing quality,
○ Scenario: Mrs. Smith is having severe pain in her right leg that is client-centered care
limiting her mobility. ● The nursing plan of care…
○ Goal: Client will report a pain score of 5 or less by the end of shift. ○ Defines the client’s problems
○ Expected outcome: Client will be able to transfer from the bed to the ○ Defines the nurse’s role in the clients treatment
chair ○ Provides continuity of care
● Outcomes must be specific and measurable. ○ Promotes interdisciplinary practice
● Nursing diagnosis: NANDA
NANDA AND NOC ● Goal: client centered
● Expected outcome: NOC (Nursing Outcome Criteria)
● To support nursing practice, the Nursing Outcomes Classification (NOC) was
● Interventions: NIC (Nursing Intervention Criteria)
developed to accompany each NANDA goal.
○ Nursing diagnosis: NANDA
○ Goal: client centered CRITICAL PATHWAYS CARE PLANNING
○ Expected outcome: NOC ● Critical pathways are evidence-based guidelines that help meet expected
outcomes by detailing specific steps in client care
PLANNING INTERVENTIONS ● What can be a critical pathway?
○ Decreasing length of stay
● Nursing interventions are actions that nurses perform to enhance the health
○ Improving pain outcomes
of clients.
○ Decreasing the cost of care
● Know the rationale for the intervention.
○ Preventing disease specific complications
● Possess the psychomotor and interpersonal skills.
● Be able to function within a setting and use the facility's resources
effectively.

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IN A NUTSHELL… ● Interpersonal skills - Developing trusting relationships and communicating
● Each nursing diagnosis is accompanied by a goal, expected outcomes, and effectively
interventions. ● Psychomotor skills - Integration of cognitive and motor activities
● A plan of care is essential to defining care, providing consistency in care,
and promoting interdisciplinary practices. DIRECT CARE vs INDIRECT CARE
● Critical thinking is an essential skill in developing quality care plans and care
● DIRECT CARE
mapping
○ Treatments performed through interactions with clients
● INDIRECT CARE
IMPLEMENT ○ Treatments performed away from the client but on behalf of the client
NURSING INTERVENTION
● A nursing intervention is any treatment based on clinical judgment and DIRECT CARE INDIRECT CARE
knowledge that a nurse performs to enhance outcomes for the client or in ● Risk reduction ● Documentation of care
the community. ● Assessments ● Communication within the
● Medications administration healthcare team
● Participation in therapy ● Care coordination
CRITICAL THINKING IMPLEMENTATION
● ADLs ● Delegation when appropriate
● Medical condition Interventions Implementation Plan ● Diagnostics ● Evaluation of care
● Possible outcomes ● Interdisciplinary care plans
● Expected response
TEAMWORK AND DELEGATION
STANDARD NURSING INTERVENTIONS
Guidelines for the selection of interventions:
● Clinical practice guidelines and protocols
○ Guide interventions for specific healthcare problems or conditions
● Standing orders
○ Prescribed instructions or procedures to be performed in the event
that a medical condition arises or changes
● NIC interventions
○ Research-based standardized classifications of interventions that
nurses perform on behalf of clients
● When you delegate aspects of a client’s care, you are responsible for
● ANA Standards of Professional Nursing Practice
ensuring that each task is assigned appropriately and is completed according
○ To be used as evidence of the standard of care
to the standard of care
IMPLEMENTATION PROCESS
Reassess and validate client needs→ Revise the plan of care → Organize care ACHIEVING CLIENT GOALS
→ Limit risk for complications

NURSING SKILLS FOR IMPLEMENTATION

Nurses implement care to meet client goals.
● Cognitive skills - Application of critical thinking

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● Interventions EVALUATING EFFECTIVENESS OF INTERVENTIONS
○ Multiple interventions may be needed
● Collaborate with the client and family
● Priorities
● Use evaluative measures.
○ Help to anticipate and sequence nursing interventions
● Interpret and summarize findings.
● Client adherence
● Document results.
○ Clients and families invest time in carrying out required treatments
● Revise care plan as needed
IN A NUTSHELL…
● Critical thinking is essential when implementing care. STEPS FOR EVALUATING OUTCOMES
● Standard interventions can be used as evidence-based guidelines for STEPS EXAMPLES
providing client care. 1. Review desired outcomes. Oxygen saturation will remain above
● Both direct and indirect interventions guide the care team toward achieving 90% on room air
set goals. 2. Review actual outcomes. Oxygen saturation is 86% on room air
3. Compare desired outcomes with Actual outcome is not meeting desired
EVALUATE actual outcomes. outcome.
4. Identify discrepancies. Client oxygen saturation is too low when
DESIRED AND UNDESIRED EVALUATIONS on room air
● Positive/desired evaluations 5. Identify barriers and revise care Client is not able to properly use
○ These occur when desired outcomes or SMART goals are met. plan. incentive spirometer because of delirium.
○ Interventions were successful.
● Unmet/undesired evaluations DISCONTINUING A CARE PLAN
○ These occur when the desired outcomes or SMART goals are not met.
Discontinue a care plan when:
○ Interventions were not successful.
● A client goal was met successfully.
● The client agrees.
GOALS OF CARE Document the discontinued plan.
Evaluation competencies from the ANA
● Communicate results. MODIFYING A CARE PLAN
● Use criterion-based evaluation measures.
Modify a care plan when:
● Collaborate.
● Client care priorities change.
● Be systematic.
● Interventions are not effective or are no longer appropriate
● Reassess and revise the care plan as needed.
Document the modified plan.

GOALS AND EXPECTED OUTCOMES IN A NUTSHELL…

● SMART goal ● Desired and undesired evaluations are helpful in developing care plan.
○ A specific statement that describes the desired change in a client’s ● The standards for evaluation as outlined by the ANA should be used to
condition or behavior evaluate if the SMART goals were met.
● Expected outcome ● The evaluation process should be used to decide if a care plan needs to
○ End result that is measurable, desirable, and can be observed in the be discontinued or modified.
client’s condition

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 ● EXPERIENCE – nursing knowledge put to the test in practice
NURSING PROCESS ● STANDARDS – using intellectual and professional standards as criteria for
the appropriateness of clinical decisions and judgements
WHAT IS NURSING?
● ATTITUDES – responsibility, confidence, fairness, integrity, creativity, etc…
● The diagnosis and treatment of HUMAN RESPONSES to actual or
potential health problems (American Nurses’ Association, 1980)

NURSING PROCESS
● Is a rational, systematic, step by step method of planning and providing
nursing care to patients and their families
● It is cyclical – it follows a logical sequence
● It is a series of planned actions by the nurse directed towards a particular
result or goal
● It is a framework for nursing practice

WHY IS IT IMPORTANT?
● It individualizes patient care – leads to improved quality of care
● It enables the patient to participate in his/her own care
● It promotes continuity of care STEPS OF THE NURSING PROCESS
● It provides a framework for accountability and responsibility
● ADPIE - ASSESSMENT, DIAGNOSIS, PLAnning, IMPLEMENTATION,
EVALUATION
CRITICAL THINKING AND THE NURSING PROCESS
● CRITICAL THINKING Case: A patient with high body temperature
○ Reasoning process by which an individual REFLECTS and ANALYZES ● Assessment: - check vital signs, look for signs/symptoms of abnormal
his/her own thoughts, actions and decisions and those of others temperature
○ It involves using one’s mind to make conclusions, make decisions, draw ● Diagnosis: patient is having altered body temperature (FEVER)
inferences, reflect on the process and the outcomes ● Plan: reduce the body temperature to normal
○ Example: ● Implementation: perform sponge bath/cold compress, tell patient to
■ A man is walking in an unknown street. He sees a hole and walks increase fluid intake, give medicine as ordered by doctor
through it. He falls. After some time, the man walks on the same ● Evaluation: recheck vital signs and determine if within normal range
street. He sees the hole. If he is a CRITICAL THINKER, he
avoids it. Iif he is not, then he walks through it and falls again
■ In the hospital, you see a patient having chills, difficulty in ASSESSMENT
breathing and in an uncomfortable condition. If YOU are a ● First phase of the nursing process but continues throughout
CRITICAL THINKER, you will go to the patient, see what the ● Purposes:
problem is…and try to HELP. If YOU are NOT, then you just ○ Establish an initial database (initial)
watch the patient undergo a bad hospital experience ○ Build and maintain the database (ongoing)
● Types:
KEY COMPONENTS OF CRITICAL THINKING IN NURSING ○ General and comprehensive (initial)
○ Focused (once problems are identified)
● KNOWLEDGE BASE – includes all that the nurse has learned in her
education and training

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 ACTIVITIES ● SECONDARY
○ Sources other than patient
DATA COLLECTION ○ Significant others (parents & relatives) – good source for patients
● Gathering of important, relevant and appropriate patient data or information who are young, unconscious or confused
● Basic human needs ○ Health Personnel – give information regarding changes in the health
● Activities of daily living status since they are in close contact with patients
● Functional health patterns ○ Records – medical and laboratory reports of past and previous illness
patterns help in the plan of care
IDENTIFYING SUBJECTIVE AND OBJECTIVE DATA ○ Literature – can provide recent trends and approaches to the patient’s
care
● Helps in the critical examination of data as they complement and clarify each
other
METHODS OF DATA COLLECTION
● SUBJECTIVE DATA
○ Also referred to as SYMPTOMS ● OBSERVATION
○ “known and experienced” only by the patient ○ Gathering of data using the 5 senses
○ Includes sensations, feelings, attitudes, beliefs, values, etc. ○ A conscious, deliberate skill that is developed only through effort and
● OBJECTIVE DATA an organized approach
○ Also referred to as SIGNS ● INTERVIEW
○ They are detected by an observer (the nurse) and can be measured or ○ Planned communication or conversation with a purpose
tested against an acceptable standard ○ Makes use of open and closed ended questions to facilitate gathering
○ They can be seen, felt, smelled and heard through observation and of data
physical assessment ● EXAMINATION
○ A systematic data collection method that uses observation to detect
health problems and validate initial cues and clues
SUBJECTIVE OBJECTIVE
○ Cephalocaudal (head to toe) in approach and makes use of
“I feel warm.” Temp: 37.80C; warm to touch
inspection, palpation, percussion and auscultation
Report of itchiness on face Scratching the face; presence of red
marks on face
“My stomach makes me sick.” Vomited 3x with greentinged fluid; ORGANIZING AND CLUSTERING DATA
abdomen is firm and distended ● A process of determining relationships in the data and finding patterns in the
“I feel afraid of the surgery.” Patient cannot sit still; trembling or slight facts
shaking of hands ● Example: A patient complaints of abdominal pain (subjective interview data),
OTHER EXAMPLES: OTHER EXAMPLES: he is grimacing and holding his abdomen (objective observation) and reports
● Burning sensation on urination ● BP = 120/70 mmHg passing loose stools (subjective interview data). Color of the stools is
● tiredness ● hard mass on the abdomen greenish brown with foul smell (objective observation). Laboratory
● pain complaint ● dry mouth investigation shows he has eaten contaminated food.
● “I am afraid of injections.”
● shortness of breath VALIDATING DATA
● The nurse checks that the data is:
SOURCES OF DATA ○ a) Factual – data is accurate and not based on assumptions or
● PRIMARY misunderstandings
○ The “patient “ ○ b) Complete – the nurse looks for gaps, missing data or inconsistencies
○ Best source of data

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 RECORDING AND REPORTING 2. GENERATE TENTATIVE HYPOTHESES (MEANINGS) FROM DATA
CLUSTERS
● Writing data according to specified format
● Example: A patient complaints of abdominal pain, he is grimacing and
● Reporting of abnormal findings to proper personnel
holding his abdomen and reports passing loose stools. The stools are
greenish-brown with foul smell.
● Hypotheses: ** The patient is having diarrhea.
** The patient ingested contaminated food.
● Make decisions based on the data:
○ a. Are the data within the normal range for the patient’s age
group?
○ b. Is the functioning described by the patient typical of her
previous patterns?
○ c. What relationships exist between pieces of data?
○ d. What specific behavior patterns contribute to the health and
well-being of the client?
○ e. What are the strengths, resources and limitations of the
patient?
DIAGNOSIS
● The phase of the nursing process in which the nurse focuses on 3 main PROBLEM IDENTIFICATION
tasks: ● From the analyzed data, what are the problems of the patient?
○ Analyzing the data gathered from assessment ● Which areas of health require nursing interventions?
○ Identifying problem areas for the patient ● Which among these problem areas need IMMEDIATE ACTION or
○ Stating the patient’s problem in the form of a NURSING DIAGNOSIS intervention?
DATA ANALYSIS + PROBLEM IDENTIFICATION + FORMULATION OF A
NURSING DIAGNOSIS FORMULATION OF THE NURSING DIAGNOSIS
● The nurse formulates CAUSAL RELATIONSHIPS between the health
problems and the factors related to them
DATA ANALYSIS
● Causal factors may be environmental, sociologic, psychologic, physiologic, or
● What will the nurse do with all the data she has gathered about the patient spiritual
during assessment? - Make sense out of it and USE IT!
A. ACTUAL NURSING DIAGNOSIS
How does the nurse analyze the data? ● Refers to a situation existing in the here and now
1. COMPARE DATA AGAINST STANDARDS ● It must be resolved so that complications and potential problems may
● Normal vital signs be prevented
● Normal health patterns ● Example: A patient has fever due to an infection. He has a body
● Laboratory values temperature of 39 0C. The fever needs to be resolved so that the
● Growth and development patient will not suffer from seizure (fits), damage to vital organs and
● Personal knowledge and integration of physiology, psychology, maintain his comfort.
sociology, etc.

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 B. POTENTIAL NURSING DIAGNOSIS A 35 year old female patient is admitted in the ward. She is very weak and she has
● Refers to a problem which may develop in the future if actual nursing a low hemoglobin level of 9.1 g/dL. She is a known case of chronic iron deficiency
problems are not resolved anemia. She looks pale, thin, and complains of breathing difficulty & dizziness
● Identification of such will prevent the problem or lessen the whenever she performs activity. She wants to take a bath but she feels very tired
consequences and her breathing becomes difficult.
● Example: A patient has a fracture on the right leg. He does not move ● Activity Intolerance related to low hemoglobin level as manifested by verbal
on bed and refuses to cooperate with the nurses to do some exercises. report of weakness, tiredness, dizziness and breathing difficulty in
If this continues for a long time, he will develop pressure sores or ulcers performing activity; pallor, thin and hemoglobin level of 9.1 g/dL
due to immobility. ● Potential for Injury/Injury Risk related to weakness and dizziness

An 18 year old student nursing student was seen at the Out-Patient Department of
St. Paul Hospital due to complaints of difficulty in sleeping for the past 5 days . She PLANNING
said: “I can not sleep because I am worried about my exams next week.” She used ● A deliberative, systematic phase of the nursing process that involves
to sleep 8 hrs. but now, she barely sleeps for 4 hrs. because she keeps on DECISION MAKING and PROBLEM SOLVING
thinking. Her conjunctivae are pale, with dark circles around the eyes. She also ● It begins with the first client contact and continues until the nurse-client
complained of dizziness and feeling tired all the time. relationship ends
● Problem: difficulty of sleeping ● Occurs from client ADMISSION to DISCHARGE
● Nursing Diagnosis: Sleep Pattern Disturbance
● Etiology: worrying and thinking about exams PURPOSES OF PLANNING
● Signs/Symptoms: ● To determine whether the client’s health status has changed
○ Subjective: patient stated: “I can’t sleep because I am worried about my ● To set priorities for the client’s care
exams next week.”; patient verbalized sleeping only for 4 hrs.; ● To decide which problems to focus on
complained of dizziness and feeling tired all the time ● To coordinate the nurse’s activities so that more than one problem can be
○ Objective: pale conjunctivae with dark circles around the eyes addressed

ACTIVITIES DURING PLANNING

● Prioritizing problems/diagnoses
● Formulating goals/desired outcomes
● Selecting nursing interventions
● Writing nursing orders
○ The output of the PLANNING PROCESS is a NURSING CARE PLAN

1. SETTING PRIORITIES FOR PROBLEM/DIAGNOSIS

● PRIORITY SETTING – process of establishing a preferential
sequence for addressing nursing diagnoses and interventions ▪ Which
nursing diagnosis or problem requires attention first? Which is second
and which is last?
● HIGH PRIORITY PROBLEMS – life threatening such as loss of
respiratory or cardiac function
● MEDIUM PRIORITY PROBLEMS – health threatening problems such
as acute illness, pain and decreased coping ability

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 ● LOW PRIORITY PROBLEMS – those that require minimal nursing ● For every nursing diagnosis, the nurse must write at least ONE DESIRED
support OUTCOME, that when achieved, directly demonstrates resolution of the
● PRIORITIES CHANGE as the client’s responses, problems and problem
therapies change ● Questions to ask:
● It is not necessary to resolve ALL high-priority diagnoses before ○ What is the problem clause?
addressing others ○ What is the opposite, healthy response?
● Nurses usually use the MASLOW’s hierarchy of needs as basis for ○ How will the client look or behave if the healthy response is achieved?
prioritizing problems ○ What must the client do and how well must he do it to demonstrate
● Other factors to be considered: resolution of the problem?
○ Client’s health beliefs and values
○ Client’s priorities COMPONENTS OR A GOAL/DESIRED OUTCOMES STATEMENT
○ Resources available
SUBJECT(PATIENT) + VERB (BEHAVIOR) + CONDITIONS (MODIFIERS) +
○ Urgency of the health problem
CRITERIA of PERFORMANCE + TIME (if needed)
○ Medical treatment plan
● SUBJECT – the client or patient
● VERB – specifies the OBSERVABLE action or behavior that the client is to
2. ESTABLISHING CLIENT GOALS OR DESIRED OUTCOMES
perform
● These are observable client responses that the nurse hopes to
● CONDITIONS (modifiers) – explains the circumstances under which behavior
achieve by implementing nursing interventions
is to be performed
● Goals – broad statement about the client’s health status
● CRITERIA of PERFORMANCE – indicates the standard or level by which the
● Desired Outcomes – observable and more specific criteria used to
patient will perform the behavior
evaluate whether the goals have been met
● TIME - clarifies how long it would realistically take for the patient to reach the
● Example:
level of functioning stated in the criteria of performance
○ Goal: The patient will improve sleep pattern
○ Desired Outcome: sleeps 8 hours a day reports feeling rested
SUBJECT VERB CONDITIONS CRITERIA TIME
and energized reports uninterrupted sleep
The patient Will drink 2500 mL of fluid without vomiting within 8 hours
The patient Will walk the length of the with a cane one day after
PURPOSE OF GOALS / DESIRED OUTCOMES ward corridor surgery
● Provide direction for planning nursing interventions The patient Will urinate 500-1000 mL after taking in the next 2-3
● Serve as criteria for evaluating client progress diuretics hours
● Enable the client and the nurse and client to determine when the problem has The patient Will report reduction in pain from a scale of after 1-2 hours
been resolved felt 8 to 5 with
● Help motivate the nurse and client by providing a sense of achievement administration
of analgesics
GOALS / DESIRED OUTCOMES AND NURSING DIAGNOSIS The patient Will perform ADL such as with minimal 2 days after
● GOALS are derived from the client’s NURSING DIAGNOSES or PROBLEM bathing, oral assistance from surgery
● Example: hygiene, dressing, nurse or relative
○ Nursing Diagnosis: Fluid Volume Deficit related to diarrhea feeding
○ Goal Statement: The patient will be able to maintain fluid balance as
evidenced by normal skin turgor, moist mucus membranes, intake is
equal to output measures

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IMPLEMENTATION 3. IMPLEMENTING THE NURSING INTERVENTIONS
● The nurses actions may be dependent or independent
● Nursing process is action oriented , client centered and outcome directed ● It is important to explain to the client what intervention will be done
● Based on assessment and diagnosing phases the nurse implements the ● Ensure client privacy
interventions and evaluating the desired outcome ● GUIDELINES
● Implementing is the action phase in which the nurse performs the nursing ○ Basic nursing interventions on scientific knowledge , nursing
interventions research ,and professional standards of care (evidence based
● Consist of doing and documenting the activities practice) when there exists
○ Clearly understand the interventions to be implemented and
IMPLEMENTING SKILLS question any that are not understood
COGNITIVE SKILLS ○ Adapt activities to the individual client
● Problem solving ○ Implement safe care
● Decision making ○ Provide teaching, support and comfort
● Critical thinking ○ Be holistic
○ Respect the dignity of the client and enhance the client self esteem
INTERPERSONAL SKILLS ○ Encourage client participation in care
● Verbal non verbal communication
● Therapeutic communication 4. SUPERVISING THE DELEGATED CARE
● If care delegated to other health care personnel, the nurse responsible
TECHNICAL SKILLS for the clients overall care
● Manipulating equipment ● Ensure that the activities have been implemented according to the care
● Giving injections plan
● Bandaging
● Moving ,lifting and repositioning the client 5. DOCUMENTING THE NURSING ACTIVITIES
● Nurse complete the implementing phase by recording the interventions
and client responses in the progress note
PROCESS OF IMPLEMENTING ● Part of permanent client record
1. REASSESSING THE CLIENT ● Nursing actions are communicated through verbally as well as writing
● Before implementing an intervention, the nurse must reassess the client
to make sure the interventions still needed.
EVALUATION
2. DETERMINING THE NURSES NEED FOR ASSISTANCE ● Evaluating is the fifth and last phase of the nursing process
● When implementing some nursing interventions , the nurse may require ● Evaluating is a planned ,ongoing , purposeful activity in which clients and
assistance for one or more of the following reasons health care professionals determine
○ Assistance would reduce the stress on the client ○ The client progress toward achievement of goals and outcomes
○ The nurse unable to implement the nursing activity safely or ○ Effectiveness of the nursing care plan
efficient alone ● Help to determine whether the nursing interventions should be terminated,
○ The nurse lacks the knowledge or skills to implement a particular continued or changed
nursing activity ● Evaluation is continuous
● Performed at specified intervals
● Through evaluating , nurses demonstrate responsibility and accountability for
their action

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 PROCESS OF EVALUATING ■ The actual problem still exists even though some goals are
being met
1. COLLECTING THE DATE RELATED TO THE DESIRED OUTCOMES
○ When goals partially met or not met
● Using clearly stated ,precise and measurable desired outcomes as a
■ The care plan may need to be revised, since the problem is
guide
only partially resolved
● Conclusions can be drawn about whether goals have been met
■ The care plan does more not need revise , because the client
● Collect both subjective and objective data
merely need more time to achieve previously established
● Data must be recorded concisely and accurately to facilitate the next
goals
part of the evaluating process
5. CONTINUING, MODIFYING OR TERMINATING THE NURSING CARE
2. COMPARING DATE WITH OUTCOMES
PLAN
● Both the nurse and client play an active role in comparing the clients
● After drawing the conclusion about the status of the clients problem ,
actual responses with the desired outcome
the nurse modifies the care plan as indicated
● Three possible conclusions,
○ The goal was met
○ The goal was partially met
○ The goals was not met
● After determining whether the goal met , the nurse write an evaluative
statement
● Evaluation statement
○ Consist of two parts a conclusion and supportive data

3. RELATING NURSING ACTIVITIES WITH OUTCOMES

● Determining whether nursing activities had any relation to the outcome
● It is important to establish the relationship for the nursing actions to the
client responses

4. DRAWING CONCLUSIONS ABOUT PROBLEM STATUS

● The nurses uses the judgments about goal achievement to determine
whether the care plan was effective in resolving , reducing or preventing
client problem
● Conclusions
○ When goals met , d95d39
■ The actual problem stated in the nursing diagnoses has been
resolved f18805
■ The potential problem is being prevented eeb1d5

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