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Chapter 6
Critical Thinking and
the Nursing Process
NURSING CONCEPTS
Collaboration
Communication
Evidenced-Based Practice
KEY TERMS
Analysis—The examination of data and identification of
client problems, nursing diagnoses, and/or needs; it
is the second step of the nursing process
Assessment—The ongoing, systematic collection,
validation, and documentation of data; it is the first
step of the nursing process
Critical thinking—A cognitive strategy by which one
reflects on and analyzes personal thoughts, actions,
and decisions
Data—Collected information
Delegate—Transferring the authority to act to another
while retaining accountability for the outcome
Evaluation—The comparison of planned expected
outcomes with a client’s actual outcomes to
determine whether client needs have been met; it is
the fifth step of the nurse process
Goal—A broad statement about the status one expects a
client to achieve
Implementation—The organization, management, and
implementation of planned nursing actions that
involves thinking and doing; it is the fourth step of
the nursing process
Nonverbal data—Observable behavior transmitting a
message without words
Nursing Interventions Classifications (NIC) system—A
standardized classification of nursing interventions
Patient-Centered Care
Professionalism
Nursing Outcomes Classification (NOC) system—A
standardized classification of client outcomes that
respond to nursing interventions
Nursing process—A critical thinking framework that
involves assessing and analyzing human responses to
plan and implement nursing care that meets client
needs as evidenced by the evaluation of client
outcomes; consists of assessment, analysis, planning,
implementation, and evaluation
Objective data (also known as signs)—Overt,
measurable assessments collected via the senses
Outcome—A specific desired change in a client’s
condition as a result of nursing interventions
Planning—The identification of goals and/or outcomes
and nursing interventions that address client
problems, nursing diagnoses, or needs; it is the third
step of the nursing process
Priority—Something ranked highest in terms of
importance or urgency
Subjective data (also known as symptoms)—Covert
information, such as feelings, perceptions, thoughts,
sensations, or concerns, that are shared by the client
and can be verified only by the client
Verbal data—Spoken or written messages
135
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136 Unit 2 Essential Nursing Care Concepts

I. Critical Thinking
Critical thinking involves mental strategies associated
with problem-solving, decision making, use of the scien-
tific method, and diagnostic reasoning. When critical
thinking is applied to the practice of nursing, it is called
the nursing process. Before one can employ the nursing
process, consisting of assessment, analysis, planning,
implementation/intervention, and evaluation, one must
first have a better understanding of what is critical think-
ing. The helix of critical thinking schematically represents
the concept of critical thinking (Fig. 6.1). The helix
consists of cognitive and personal competencies (Fig. 6.2).
The helix of critical thinking can be applied to the nursing
process (Fig. 6.3).
A. Introduction to critical thinking
1. Critical thinking is a cognitive strategy by which
you reflect on and analyze your thoughts, actions,
and decisions; it requires internal cognitive and
personal competencies (see Fig. 6.2).
2. Cognitive competencies.
a. Cognitive competencies are the intellectual or
reasoning processes used when thinking and
include such skills as the ability to understand,
analyze, interpret, correlate, investigate, com-
pare and contrast, categorize, determine signifi-
cance, query evidence, establish priorities, make
inferences, and determine consequences, to
name a few.
b. The more internal cognitive competencies a per-
son can bring to the thinking process, the more
successful a person will be at thinking critically.
3. Personal competencies.
a. Personal competencies are the attitudes and
characteristics that are associated with suc-
cessful critical thinkers, such as being an
independent thinker, open-minded, imagina-
tive, disciplined, committed, accountable,
inquisitive, confident, reflective, objective,
intuitive, rational, curious, honest, and moral,
to name a few.
b. The more personal competencies a person can
bring to the thinking process, the more success-
ful a person will be at thinking critically.
B. Maximize your critical thinking ability
1. Self-analysis: The competencies listed previously
are just a few of the competences in each category.
Make a list or your own competencies. This will
enable you to identify additional skills and abilities
that you need to work on acquiring.
2. Techniques to improve critical thinking. Fig 6.1 The helix of critical thinking. (From Nugent and Vitale
a. Study your textbooks and other resources. A [2015]. Fundamentals success, 4th ed. Philadelphia: F. A. Davis
strong knowledge base is essential to thinking Company, with permission.)
critically.
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Chapter 6 Critical Thinking and the Nursing Process 137

b. Reflect on your learning. Examine your per-

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

II. Introduction to the Nursing Process

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

III. Assessment
Assessment, the first step of the nursing process, is the
ongoing, systematic collection, validation, and documen-
tation of data. Data are information. Nursing assessment
should be comprehensive, holistic, and accurate so that
it provides all the necessary information about a client.
In addition, it should reflect the client’s responses to a
health problem and stressors, not disease processes.
Adequate assessment depends on collecting data using
various methods, collecting both subjective and objective
data, verifying that data are accurate, and communicat-
ing information about assessments to other members of
the health team.
A. Methods of data collection
1. Physical examination: The use of inspection,
Fig 6.2 The helix of critical thinking schematically elon- auscultation, percussion, and palpation to collect
gated. (From Nugent and Vitale [2015]. Fundamentals success, data about a client’s physical status. (See “Tech-
4th ed. Philadelphia: F.A. Davis Company, with permission.) niques of Physical Assessment Used by Nurses,”
in Chapter 14, Physical Assessment.)
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138 Unit 2 Essential Nursing Care Concepts
Fig 6.3 The interactive nature of the helix of critical thinking within the nursing process. (From
Nugent and Vitale [2015]. Fundamentals success, 4th ed. Philadelphia: F. A. Davis Company, with permission.)
2. Interviewing.
a. Formal approach.
(1) Used when collecting information in an
arranged or official way, such as for a
history and physical.
(2) Usually involves direct rather than
open-ended questions.
b. Informal approach.
(1) Used when collecting data in a casual
and more relaxed manner, such as when
exploring a client’s feelings while providing
other nursing care.
(2) Usually involves open-ended questions.
c. See also “Communication,” “Therapeutic
and Nontherapeutic Communication,” and
“Nursing Care Related to Communication”
in Chapter 2, Communication, Collaboration,
and Documentation.
3. Clinical record review.
a. Involves monitoring information collected
about the client in the clinical record.
b. Gathers information about results of laboratory
examinations, diagnostic procedures, consulta-
tions by other members of the health team, and
progress notes.
B. Sources of data
1. Primary source.
a. The client is the only primary source of data.
The data include information such as feelings,
physical and emotional perceptions, and beliefs.
! b. The client is the most valuable source because the
data collected are most recent, unique, and specific
to the client.
2. Secondary sources.
a. These sources provide supplementary informa-
tion about the client from some place other
than the client but within the client’s frame
of reference.
b. They include people other than the client (e.g.,
family members, friends, other health team
members).
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MAKING THE CONNECTION
Application of Critical Thinking
to the Nursing Process
Critical thinking is a cognitive strategy by which one
reflects on and analyzes personal thoughts, actions, and
decisions. It involves purposeful, goal-directed thinking
(e.g., the nursing process); requires judgment based on facts
and principles of science rather than conjecture or trial
and error (e.g., evidence-based practice); and requires
numerous cognitive and personal competencies. The helix
of critical thinking (Fig. 6.1) demonstrates the interwoven
relationship between cognitive competencies and per-
sonal competencies essential to thinking critically.
Throughout the thinking process, there is constant inter-
action among cognitive competencies, among personal
competencies, and between cognitive and personal
competencies. The more cognitive competencies and per-
sonal competencies a person possesses, the greater the
potential the person has to think critically (Fig. 6.2). Critical
thinking has an interactive relationship with the nursing
process. The nursing process is a dynamic, cyclical process
in which each phase interacts with and is influenced by
the other phases of the process. Critical thinking is an
essential component within, between, and among the
phases of the nursing process. Different combinations of
cognitive and personal competencies may be used during
the different phases of the nursing process (Fig. 6.3).
c. A client’s clinical record is also a secondary
source, as it contains a vast amount of informa-
tion about the client’s physical, psychosocial,
and economic history as well as information
about the client’s progress regarding physical
and emotional responses to a health problem.
DID YOU KNOW?
Although a client’s clinical record is a secondary
source, laboratory and diagnostic procedure results
are direct objective measurements of the client’s
status and are considered by some to be a primary
source. The clinical record is a historical view of the
client and, for that reason, is less current than data
collected from the client.
3. Tertiary sources.
a. These sources produce data from outside the
client’s frame of reference.
b. Examples include information from textbooks,
surveys, medical and nursing journals, drug
books, and policy and procedure manuals.
C. Types of data
1. Objective data.
a. Objective data (also known as signs), are overt,
measurable assessments collected via the
Chapter 6 Critical Thinking and the Nursing Process 139
senses, such as sight, touch, smell, and hearing,
and compared to an accepted standard.
b. Examples include body temperature, pulse and
respiratory rates, blood pressure, vomiting,
distended abdomen, presence of edema, lung
sounds, crying, skin color, and presence of
diaphoresis.
2. Subjective data.
a. Subjective data (also known as symptoms) are
covert information, such as feelings, percep-
tions, thoughts, sensations, or concerns that
are shared by the client and can be verified
only by the client.
b. Examples include pruritus, nausea, pain,
numbness, attitudes, beliefs, values, and
perceptions of the health problem and life
circumstances.
3. Verbal data.
a. Verbal data are spoken or written messages.
b. Requires the nurse to listen to the pace of the
communication pattern, tone of voice, vocabu-
lary used, and presence of aggression, anxiety,
or assertiveness.
c. Allows for the assessment of difficulties such as
slurring, lack of clarity, flight of ideas, difficulty
finding the desired word, and inability to iden-
tify an item.
d. Examples include statements made by the client
or by a secondary source.
4. Nonverbal data.
a. Nonverbal data are observable behavior trans-
mitting a message without words.
b. Examples include client’s appearance; facial
expression; body language, such as posture,
gestures, and eye contact or lack of eye contact.
D. Verifying collected data
1. Data must be double-checked (verified) after they
are collected.
2. Ensures validity and accuracy.
3. Ensures that the nurse does not come to a con-
clusion without adequate data to support the
conclusion.
4. Involves collecting additional information to
support the initial data.
a. If a client’s pulse is increased above the expected
range, the nurse should take the pulse again; if
it is still increased, the nurse should collect
other vital signs to supplement the original
information.
b. If a client says, “I feel that I am in a big, black
hole,” the nurse might use the communication
technique of clarification to have the client
explain in more detail what was meant: “Tell
me more about this big, black hole that you
feel you are in.”
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140 Unit 2 Essential Nursing Care Concepts
E. Communicating collected data
1. Outcomes of nursing assessments must be docu-
mented on correct forms and in appropriate
places in the client’s clinical record. Many forms
are used to document data and are organized by
topic or body systems.
2. Communicating data ensures that pertinent and
current information relative to the client is shared
with other members of the health team.
! 3. Data must be communicated in an objective and
factual way and not be a summary of the nurse’s
interpretation of the data.
4. Value words, such as good, bad, adequate, poor,
and tolerated well, should be avoided. For exam-
ple, rather than saying that a client’s appetite is
poor, the nurse should document that the client
ate half of a scrambled egg and a slice of toast. This
manner of documentation communicates objec-
tive, measurable information about the client’s
appetite.
5. Value words related to a client’s behavior, such as
lazy, difficult, stubborn, rude, uncooperative, and
foolish, should be avoided. These words reflect a
value judgment made by the nurse that may be
influenced by bias and personal values or beliefs.
Nurses must always be nonjudgmental.
6. Subjective data should be documented in the exact
words expressed by the client and put in quotation
marks; this practice ensures that a client’s meaning
is not misinterpreted or inaccurately altered by
words used by the nurse to describe an event.
IV. Analysis
B. Interpreting data
Analysis, the second step of the nursing process, requires
the nurse to use critical thinking strategies to scrutinize
data. Activities associated with this step include clustering
data, interpreting data, and identifying and communicat-
ing a client’s nursing diagnoses, problems, or needs.
A. Clustering data
1. Involves grouping information into related cate-
gories, a beginning effort to organize and manage
information.
2. Data can be clustered into general categories,
such as physiological, sociocultural, psychological,
and spiritual. Then each category may be further
reduced into specific categories, such as nutrition,
mobility, elimination, and oxygenation.
3. Data can be easy or difficult to cluster depending
on the amount and variety of data collected.
4. Easy-to-cluster information commonly involves
only one body system. For example, a client
reports feeling low abdominal pressure, has not
voided in 8 hours, and has abdominal distention
on palpation of the suprapubic area; these clinical
indicators all relate to urinary elimination and
lead to the interpretation that the client may
have urinary retention.
5. Difficult-to-cluster information may at first
seem unrelated because a variety of body systems
are involved. For example, a client has a weak,
thready pulse; decreased blood pressure; rapid res-
pirations; pallor; and clammy skin; these clinical
indicators cross body systems, but all are related
to hypovolemic shock.
6. Inductive reasoning moves from the specific to
the general. For example, if you identify that a
client has a temperature and a wound with puru-
lent drainage, you may come to the conclusion
that the wound is infected.
7. Deductive reasoning moves from the general to
the specific. For example, if you know that a newly
admitted client has a wound infection, you might
deduce that the client will have a temperature,
purulent drainage, and a culture and sensitivity
laboratory result identifying the causative agent.
8. Data must be clustered before it can be interpreted.
9. Established frameworks are available to provide
structure for organizing clustered data.
a. Abraham Maslow’s hierarchy of human needs.
b. Marjory Gordon’s functional health patterns.
c. NANDA International (formerly the North
American Nursing Diagnosis Association)
nursing diagnosis taxonomy.
10. Most health-care agencies have their own
admission assessment forms, which commonly
follow a systems approach to collecting and
clustering data.
1. Interpreting data requires identifying the signifi-
cance of clustered data.
2. Determining significance requires a comparison of
data collected with a wide range of standards and
norms (e.g., expected vital signs and laboratory
values, growth and development patterns and
milestones, and cause-and-effect relationships).
The nurse must then come to a conclusion about
a specific identified pattern. It also involves query-
ing evidence, exploring alternatives, and drawing
initial conclusions.
3. Conclusions are drawn after the significance of
data is determined. Conclusions are the opinions,
perceptions, judgments, and inferences that result
from the interpretation of data.
4. More data may be necessary to support an initial
conclusion, thereby increasing validity and
reliability.
a. When a client has an increased blood pressure,
pulse, and respiratory rate and is rubbing a
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shoulder, the nurse makes an inference that
the client is experiencing pain. To validate this
conclusion, the nurse asks, “I noticed that you
are rubbing your shoulder. Is it causing you
discomfort?”
b. If a client says, “I feel as though my bladder will
burst,” the nurse makes the inference that the
client might be experiencing urinary retention.
To validate this, the nurse should palpate the
client’s abdomen for distention. The nurse
also can ask questions that clarify the client’s
statement.
5. Nurses should ask the following questions after
arriving at conclusions.
a. “Did I miss anything?”
b. “What else do I need to know?”
c. “Has the client’s condition or situation changed
since I initially assessed the client?”
d. “Are there any inconsistent or conflicting data
that require clarification?”
e. “Is my data cluster complete, or do I need to
collect additional data to better support my
conclusion?”
C. Identifying nursing diagnoses
1. Introduction to nursing diagnoses.
a. Nursing diagnoses are statements of specific
health problems that nurses are legally allowed
to independently identify, prevent, and treat.
b. They convert an initial conclusion into a diag-
nostic statement.
c. They logically link the assessment step to the
planning, implementation, and evaluation
steps of the nursing process.
d. NANDA International provides a taxonomy
of diagnostic labels and etiologies.
e. Each nursing diagnosis in the taxonomy follows
the same organization for the presentation of
information.
(1) Diagnostic label (title or name): A word or
phrase that is based on a pattern of inter-
connected data. For example, Impaired
skin integrity.
(2) Definition: Explains the meaning of the
diagnostic label, which differentiates it
from similar nursing diagnoses. For exam-
ple, Altered epidermis and/or dermis.
(3) Defining characteristics: Identifies clinical
indicators (signs and symptoms) that
support the diagnostic label. For example,
Invasion of body structures, destruction
of skin layers (dermis), disruption of skin
surface (epidermis).
(4) “Related to” factors: Situations, events,
or conditions that precede, cause, affect,
or are in some way associated with the
Chapter 6 Critical Thinking and the Nursing Process 141
diagnostic label. For example, Related to
physical immobilization. The list of related
factors in the taxonomy is not all-inclusive
because it is impossible to list all possible
factors.
DID YOU KNOW?
Although nursing diagnoses provide a framework
for identifying a client’s nursing problems using a
standardized nomenclature or language, some
professionals believe that they have become too
complex and abstract to be useful in everyday
practice. As a result, some areas of practice are
moving away from using nursing diagnoses.
D. Communicating client nursing diagnoses, problems,
or needs
1. Nurses communicate client nursing diagnoses,
problems, or needs in a written plan of care.
MAKING THE CONNECTION
NANDA Taxonomy and a Nursing Diagnosis
A nurse is caring for a newly admitted client who has
paralysis of the legs as a result of a spinal cord injury
several years ago. The client sits in a wheelchair most
of the day and lies in the supine position when sleep-
ing. The nurse identifies that the client has a shallow,
round, partial-thickness loss of dermis over the sacrum.
The wound bed is red with no evidence of sloughing.
The nurse identifies the nursing diagnosis: Impaired
skin integrity (diagnostic label) related to physical
immobilization (related to factor). Because the nurse
understands that there can be more than one “related
to” factor, the nurse includes all the causes of the
client’s impaired skin and develops this nursing diag-
nosis: Impaired skin integrity related to physical immo-
bilization, altered sensation, and pressure. The nurse
expands the nursing diagnosis to include “secondary
to” information to make the etiology clearer. Often,
“secondary to” information is a pathophysiological
process or medical diagnosis. The nursing diagnosis
is now: Impaired skin integrity related to immobility,
altered sensation, and pressure secondary to motor
deficits.
The nurse further expands the nursing diagnosis to
include “evidenced by” information to make the etiology
even more clear. Often, “evidenced by” information is
the clinical indicators (signs and symptoms) included in
the defining characteristics in the NANDA taxonomy. The
final nursing diagnosis is: Impaired skin integrity related
to inactivity, altered sensation, and pressure secondary
to motor deficits as evidenced by the inability to inde-
pendently move the legs.
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142 Unit 2 Essential Nursing Care Concepts
2. The plan of care may be kept in a variety of
places (e.g., client’s clinical record, the medication
administration record, and interdisciplinary
clinical pathways).
V. Planning
Planning, the third step of the nursing process, provides
direction for nursing interventions. It is concerned with
identifying priorities, establishing goals and expected out-
comes, and selecting nursing interventions that will help
the client achieve those goals and expected outcomes.
Planning begins when a client is admitted and is ongoing
to meet the changing or emerging needs of the client.
Effective planning includes collaboration with all appro-
priate health team members to facilitate continuity of
care in a client-centered, individualized, and coordinated
manner. Planning culminates in a document about the
proposed plan of care that is communicated to all mem-
bers of the health team.
A. Identifying priorities
1. A priority is something ranked highest in terms
of importance or urgency.
2. A nurse must place a client’s nursing diagnoses,
problems, and needs in order of importance when
confronted with a variety of client issues.
3. A nurse must have a strong foundation of scien-
tific theory, knowledge of the commonalities
and differences in response to nursing interven-
tions, and theories to determine the priority of
a client’s needs.
4. Factors that promote the prioritization of care.
a. Maslow’s hierarchy of needs.
(1) Needs are placed in order from the
most basic needs to the highest-level
needs.
(2) Physiological is the first-level need, fol-
lowed by safety and security, love and be-
longing, self-esteem, and self-actualization
(see Fig. 7.3 in Chapter 7, Evidenced-Based
Practice).
b. Urgency of the health problem.
(1) Ranks problems based on the degree of
threat to the client’s life. The nurse can
use the ABCs of assessment (Airway,
Breathing, Circulation) when determin-
ing priorities.
(2) A high-priority problem poses the greatest
threat and should be addressed first (e.g.,
an impaired airway).
(3) A medium-priority problem follows a
high-priority problem. It may be related
to harmful physiological responses that
are not an immediate threat to life (e.g.,
impaired mobility).
(4) A low-priority problem should pose the
least threat and be ranked last. It may
require minimal support (e.g., nausea).
c. Client’s priorities.
(1) Ranks client needs based on what is most
important to the client.
(2) Although a client’s preference should
always be taken into consideration, basic
life-threatening needs require urgent
interventions and override less important
needs.
d. Future impact of the client’s condition.
(1) Although a problem might not be life
threatening and is not recognized by the
client as important, the nurse may deter-
mine that it can cause future negative
consequences if not addressed.
(2) For example, a nurse identifies that a client
newly diagnosed with type 1 diabetes has
dirty feet and is wearing sandals instead
of shoes that enclose the feet. The nurse
knows that people with diabetes are at risk
for foot problems secondary to impaired
circulation to the lower extremities. There-
fore, the client has a potential for skin
breakdown, which can lead to infection
and even amputation. The nurse ranks this
issue as a priority and plans interventions
to educate the client about foot care.
B. Identifying goals and expected outcomes
1. Basic concepts.
a. A goal is a broad statement about the status one
expects a client to achieve.
b. A goal generally is derived from the “diagnostic
label” component of a nursing diagnosis. For
example, if a client has the nursing diagnosis
Ineffective airway clearance related to excessive
respiratory secretions, the goal might be: “The
client will maintain a patent airway.”
c. An outcome identifies a specific change in a
client’s condition as a result of nursing inter-
ventions. It is commonly influenced by the
“related to” component of a nursing diagnosis.
Also, it provides criteria to be used in the evalu-
ation phase of the nursing process. For exam-
ple, the outcome statement using the previously
stated goal (“The client will maintain a patent
airway”) might be: “The client will expectorate
respiratory secretions while hospitalized” (see
Box 6.1, Nursing Outcomes Classification
[NOC] System).
d. Clients and nurses together should set goals and
outcomes to ensure that these goals and out-
comes are realistic, achievable, and in alignment
with what the client and nurse want to achieve.
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Box 6.1 Nursing Outcomes Classification (NOC)
System
The Nursing Outcomes Classification (NOC) system is a
standardized classification of client outcomes that respond
to nursing interventions. Each NOC outcome has a label,
indicators, and measurement scale. The advantages of the
NOC system are that it uses language common to all health-
care professionals, it is specific, and it identifies indicators
with a measurement scale to allow nurses to evaluate client
progress toward an outcome.
Example of NOC outcomes with indicators for Impaired
skin integrity:
• Tissue integrity: Skin and mucous membranes will be intact
as evidenced by the following indicators: Skin intactness/
skin lesions/tissue perfusion/skin temperature.
• Rate each indicator of tissue integrity: skin and mucous
membranes: 1 = severely compromised, 2 = substantially
compromised, 3 = moderately compromised, 4 = mildly
compromised, 5 = not compromised.
2. Criteria for goals and outcomes.
a. Be client centered.
(1) The client is the center of the health team;
therefore, the client should be the subject
of all goals and outcomes.
(2) For example, “The client will transfer from
the bed to a chair safely within 1 week.”
Some agencies believe that the words the
client are understood and therefore do not
include them when stating a goal.
b. Contain an action verb.
(1) The goal or outcome should identify the
action that the client will learn, do, or
express or the physical status the client
will attain.
(2) For example, “The client will transfer from
the bed to chair safely within 1 week.”
c. Include performance criteria.
(1) Actions must be specific and measurable.
For example, “The client will transfer from
the bed to chair safely within 1 week.”
(2) Conditions may be included to describe the
kind of assistance or resources needed by
the client. For example, “The client will
transfer from the bed to chair safely with a
one-person assist within 1 week.”
d. Include a time frame.
(1) The goal must be achievable within a set
time frame.
(2) For example, “The client will transfer from
the bed to chair safely within 1 week.”
Additional examples of time frames include
by discharge, within 24 hours, at all times,
and will maintain (the word maintain
implies continuously).
Chapter 6 Critical Thinking and the Nursing Process 143
e. Be realistic.
(1) The performance criteria identified must
be reasonable and feasible in light of the
client’s emotional and physical status.
(2) Goals are realistic when the outcomes can
be achieved in the indicated time frames.
(3) Example of a realistic outcome for a client
who had abdominal surgery is: “The client
will exhibit bowel sounds within 3 days
after surgery.”
(4) Example of an unrealistic outcome for a
client with hemiplegia due to a brain
attack is: “The client will perform active
range-of-motion exercises independently
within 1 week.”
C. Identifying nursing interventions
1. Selecting appropriate interventions depends
on the accuracy and thoroughness of the data
collected.
2. Nursing interventions generally address the
“related to” part (etiology) of the client’s problem
or nursing diagnosis. For example, if a person is
at risk for impaired skin integrity related to urinary
incontinence and immobility, the nursing interven-
tions selected should keep the client clean and dry
and relieve pressure.
3. Nursing interventions should include nursing
assessments, nursing care to avoid complications,
administration of prescribed treatments and
medications, and health promotion and illness
prevention activities, as appropriate.
4. Selected actions should have the greatest proba-
bility of achieving the desired goal/outcome
with the least risk to the client. The nurse must
consider:
a. Cause: Planned action.
b. Effect: Client’s response.
c. Risk: Potential for the client to have a nega-
tive consequence as a result of the planned
action.
d. Probability: Degree to which the client may
have a positive consequence as a result of the
planned action.
e. Value of the consequences: Significance of
results of the planned action to the client.
5. Selected interventions should be based on
evidence-based practice—that is, interventions
that have been proven to be effective based
on rigorous scientific evidence and clinical
effectiveness studies rather than on tradition,
intuition, or anecdotal information. Nursing
practice based on evidence improves the quality
of client care and justifies nursing interventions
(see Box 6.2, Nursing Interventions Classifica-
tion [NIC] System).
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144 Unit 2 Essential Nursing Care Concepts
Box 6.2 Nursing Interventions Classification (NIC)
System
The Nursing Interventions Classification (NIC) system is
a standardized classification of nursing interventions. It
includes both physiological and psychosocial interventions
that can be performed across all nursing disciplines. It con-
sists of intervention labels. Each intervention label has a
definition and a list of related nursing actions. The advan-
tages of the NIC system are that it uses language common
to all health-care professionals, it is specific, and it is based
on evidence-based practice.
Example of NIC interventions for pressure ulcer care:
• Pressure ulcer care: Monitor color, temperature, edema,
moisture, and appearance of surrounding skin; note charac-
teristics of any drainage.
D. Communicating the plan of care
1. Plans of care promote communication and coordi-
nation among health team members, improving
the continuity of client care.
2. Information that should be included on a compre-
hensive plan of care includes:
a. Client nursing diagnoses, problems, or needs
and related independent and dependent
nursing interventions.
b. Activities of daily living (ADLs) and basic needs.
c. Medical prescriptions and the nursing
interventions required to implement them.
d. Requirements to prepare the client for
discharge, such as teaching, equipment,
and services.
3. Various types of care plans are used.
a. Computer-generated care plans can be stan-
dardized or individualized. The nurse chooses
a nursing diagnosis or health problem, and the
computer presents potential goals/outcomes
and nursing interventions. The nurse can then
select interventions that are appropriate for the
client. The computer then generates a written
printout of the plan of care.
b. Multidisciplinary care plans (collaborative
care plans, critical or clinical pathways)
sequence care that is to be delivered each
day during a client’s length of stay. Each day
has a column and vertical boxes that address
specific care that is to be delivered by each
health-care discipline.
E. Modifying the plan of care
1. Plans of care are dynamic and require modifica-
tion to keep them current and relevant.
2. The original plan of care may require changes
because the original plan was inadequate or
inappropriate or because additional assessments
provide new information.
3. A plan of care may require modification after
the evaluation step of the nursing process when
it is identified that the client did not achieve an
expected outcome or because the client’s status
improved.
VI. Implementation
Implementation, the fourth step of the nursing process,
is the actual performance of nursing actions. It is the
execution of the plan of care and involves thinking and
doing. Therefore, nurses must have not only a strong
knowledge base of the sciences, nursing theory, nursing
practice, and legal parameters of nursing interventions
but also the psychomotor skills to implement procedures
safely. Nurses must implement only nursing actions that
are described in their state’s nurse practice act and con-
form to professional nursing standards of care.
A. Legal parameters of nursing interventions
1. A nurse must know the legal parameters of
nursing interventions, which include:
a. Dependent nursing interventions.
(1) Require a prescription from a primary
health-care professional with prescriptive
privileges (e.g., physicians, podiatrists,
dentists, physician’s assistants, nurse
practitioners).
(2) Nurses must ensure that prescribed inter-
ventions and medications are appropriate
to meet the needs of a client. If a nurse
implements an inappropriate intervention
or prescription, the nurse can be held
legally accountable as a contributor to the
initial error made by the primary health-
care provider. Nurses must question
inappropriate prescribed interventions
or prescriptions and not follow them
blindly.
(3) Examples of dependent nursing interven-
tions include:
(a) Administering medications or
intravenous solutions.
(b) Implementing activity prescriptions.
(c) Inserting or removing a urinary
retention catheter.
(d) Providing a diet.
(e) Implementing wound or bladder
irrigations.
b. Independent nursing interventions.
(1) Registered nurses can legally plan and
implement independent nursing interven-
tions without supervision or direction from
a person with a prescriptive license.
(2) Each state’s nurse practice act defines the
scope of nursing practice within the state.
6069_Ch06_133-160 14/03/17 5:42 pm Page 145
(3) Examples of independent nursing interven-
tions include:
(a) Assessing a client.
(b) Diagnosing a client’s nursing needs.
(c) Planning, implementing, and evaluating
nursing care.
(d) Assisting with ADLs.
(e) Teaching any subject associated with
health promotion and illness prevention.
(f) Counseling.
(g) Advocating for a client.
(h) Encouraging a client to express
concerns and feelings.
(i) Encouraging coughing and deep
breathing.
(j) Referring a client to community
resources.
c. Interdependent nursing interventions.
(1) Nurses work in collaboration with pri-
mary health-care providers to implement
dependent nursing interventions that have
set parameters.
(2) Some settings, such as intensive care units
and birthing units, have standing protocols
that delineate the parameters within which
the nurse can implement a dependent
nursing intervention.
(3) Examples of interdependent nursing inter-
ventions include:
(a) A prescription says, “Out of bed as
tolerated.” The nurse determines
whether the client is tolerating an
activity and therefore the amount of
activity in which to engage the client.
(b) A prescription for a pain medication
states, “acetaminophen (Tylenol)
650 mg every 6 hours prn for mild
lower back pain.” The nurse assesses
the level of the client’s pain and then
decides whether to administer the
prescribed dose.
B. Types of nursing interventions
1. Assisting with ADLs.
a. Nurses assist clients with activities that people
perform daily to promote comfort, health, and
well-being.
b. Problems interfering with these actions can
be acute or chronic, temporary or permanent,
and require teaching or assistance to restore
function.
c. Examples include helping a debilitated client
eat, ambulating a client after surgery, providing
range-of-motion exercises, turning and posi-
tioning a bed-bound client, and dressing and
toileting a client.
Chapter 6 Critical Thinking and the Nursing Process 145
2. Teaching.
a. Nurses provide teaching in relation to the
cognitive, psychomotor, and affective
domains.
b. Examples include conducting a class about the
signs and symptoms of hyperglycemia (cogni-
tive domain), teaching a client how to self-
administer insulin (psychomotor domain),
and facilitating a group session of adolescents
discussing and role-playing how to say no when
pressured to engage in alcohol or drug misuse
(affective domain).
c. See Table 8.1, “Understanding Learning
Domains,” in Chapter 8, Teaching and
Learning, for more information about the
various learning domains and related nursing
strategies.
3. Responding to life-threatening events.
a. Nurses use clinical judgment to identify and
respond to life-threatening changes in a client’s
condition.
b. The related interventions generally are associ-
ated with meeting a client’s basic physiological
needs.
c. Examples include performing abdominal
thrusts for a client who is choking, implement-
ing cardiopulmonary resuscitation for a client
who has no palpable pulse and is not breathing,
and discontinuing a blood transfusion when
a client has clinical indicators of a transfusion
reaction.
4. Implementing health promotion and illness
prevention activities.
a. Nurses provide interventions that assist
people to maintain health and avoid health
problems.
b. They aim to help people who are at an increased
risk for illness because of their developmental
level, such as neonates, young children, and
dependent older adults. In addition, they help
people who are at an increased risk for negative
consequences of their behaviors, such as people
who smoke, drink alcohol excessively, misuse
drugs, have multiple sexual partners, or overeat.
They also aim to help people limit exacerbations
of illnesses and subsequent health problems
as a result of an initial illness.
c. Examples include administering a vaccine,
teaching a class about healthy nutrition, pro-
moting smoking cessation or weight reduction,
using standard precautions, and turning and
positioning an immobile client.
5. Performing technical skills.
a. Nurses must competently perform technical
psychomotor skills associated with a procedure.
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146 Unit 2 Essential Nursing Care Concepts
b. The nurse should know the steps, principles,
rationales, and expected outcomes relative to
nursing procedures to implement them in the
appropriate situation safely.
c. Examples include administering medications
via various routes, suctioning a client’s respira-
tory tract, changing a wound dressing, and
irrigating a colostomy.
6. Employing psychosociocultural interventions.
a. Nurses use therapeutic interviewing tech-
niques to encourage clients to express feelings
and concerns. Once the nurse identifies a
client’s emotional needs, the nurse continues
to support the client emotionally while explor-
ing potential coping strategies. In addition,
the nurse uses interpersonal interventions
when working as an advocate for the client,
coordinating health-care activities, and collab-
orating with others on the client’s behalf.
b. Examples include using nondirective interview-
ing techniques, gently addressing a client’s
behavior, collaborating with a client to identify
a goal, and explaining to family members that
their loved one’s angry behavior is associated
with the anger stage of grieving in response
to the diagnosis of cancer.
7. Delegating, supervising, and evaluating delegated
nursing interventions.
a. Delegation is transferring the authority to act
to another while retaining accountability for
the outcome.
b. Nurses may delegate nursing care to:
(1) Unlicensed assistive nursing personnel.
(a) Uncomplicated, basic interventions.
(b) Examples: Bathing a bed-bound
client, ambulating a stable postopera-
tive client, obtaining vital signs from
clients who are stable.
(2) Licensed practical nurse (LPN).
(a) Routine nursing care for clients who are
stable and whose care is uncomplicated.
(b) Examples: Administering medications,
changing a sterile dressing, instilling
an enema.
(3) Registered nurse.
(a) Complex nursing interventions.
(b) Examples: Performing a physical
assessment, teaching a client how to
self-administer insulin, formulating
a client’s plan of care.
c. The nurse delegating care is responsible for:
(1) Assuming responsibility for the care that is
delegated and its consequences.
(2) Ensuring that the person implementing
the care is legally permitted to provide the
delegated care, is knowledgeable, and is
able to deliver the care safely.
(3) Ensuring that the care is implemented
according to standards of care.
(4) Evaluating the client’s responses to the
interventions implemented.
(5) For additional information about delegation
see “Delegation” in Chapter 5, Leadership
and Management.
8. Reporting and documenting nursing interventions
and client responses.
a. Nurses communicate information verbally and
in writing to other members of the health team
to provide continuity of client care. Written
documentation also establishes a permanent
legal record of the care provided and the
client’s response.
b. Examples include documenting vital signs
on a client’s graphic record, indicating the
characteristics of a client’s skin integrity on
a pressure ulcer flow sheet, providing a verbal
report regarding the status of clients to a nurse
arriving for the next shift, and documenting
the administration of medications and client
responses to medications.
! c. If interventions are not documented, they are
considered not done.
VII. Evaluation
Evaluation, the fifth step of the nurse process, involves
issues related to structure, process, and client outcomes.
The nurse first reassess the client to identify client re-
sponses to interventions (actual outcomes) and then
compares the actual outcomes with the planned outcomes
(expected outcomes) to determine goal achievement. It is
a continuous process that requires the plan of care to be
modified as often as necessary either during or after care.
A. Components of evaluation
1. Structure.
a. Associated with the setting and effect of organi-
zational features on the quality or excellence of
nursing care.
b. Based on such things as policy and procedures,
economic resources, available equipment, and
the number, credentials, and experiential back-
ground of members of the nursing team.
c. Example of a structure goal against which the
delivery of nursing care can be assessed: A
controller pump is used for administration
of intravenous medication.
2. Process.
a. Associated with evaluation of clinical perfor-
mance of nursing team members.
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b. Example of a process goal against which the
care delivered by a nurse can be assessed:
The client’s privacy is maintained by pulling
the curtain and draping the client when assess-
ing a client’s wound.
3. Client outcome.
a. Associated with measurable changes in a
client’s status as a result of care implemented
by a nurse.
b. Example of an expected client outcome
against which an actual client outcome can
be assessed: The client’s skin will remain clean,
dry, and intact.
B. Types of evaluation activities
1. Routine evaluations.
a. Occur at preset regular time frames.
b. For example, obtaining clients’ vital signs every
shift; documenting intake and output every
shift and every 24 hours.
2. Ongoing evaluations.
a. Occur during and immediately after administer-
ing nursing care or after interacting with a client.
b. For example, assessing a client’s response to
irrigation of a colostomy; determining whether
a client understands the content in a teaching
session.
3. Intermittent evaluations.
a. Occur in specific situations.
b. For example, obtaining daily weights to moni-
tor a client receiving a diuretic; assessing the
degree of pain relief after a client receives an
analgesic.
4. Terminal evaluations.
a. Occur in preparation for a client’s discharge;
health-care agencies generally have a compre-
hensive discharge form that provides structure
and consistency within an agency.
b. For example, evaluating a client’s physical and
emotional status; determining progress toward
goal/outcome achievement; and formulating
a plan of care to be implemented in the com-
munity setting, including topics such as med-
ications, treatments, diet, and scheduled
follow-up care.
C. Nursing interventions to ensure thorough evaluation
of client responses to nursing care
1. Reassess the client to identify actual outcomes
(client responses).
a. The nurse must reassess the client to collect
data, organize the data, and determine the
significance of the data.
b. Actual outcomes are then compared to the
expected outcomes identified in the written
plan of care to determine whether the client
successfully achieved the goals/outcomes.
Chapter 6 Critical Thinking and the Nursing Process 147
2. Compare an actual outcome with an expected
outcome to determine goal achievement.
a. If they are the same, then the nurse can infer
that the nursing care was effective in assisting the
client to achieve the expected outcome. In other
words, a positive evaluation is indicated when an
actual outcome meets the expected outcome.
b. If they are not the same, then the nurse can
infer that the nursing care was not effective
in assisting the client to achieve the expected
outcome. In other words, a negative evaluation
is indicated when an actual outcome does not
meet the expected outcome.
c. Once it is determined that the expected out-
come was not achieved, the nurse must analyze
factors that may have affected the actual out-
comes of care.
3. Analyze factors that may have influenced
nonachievement of expected goals/outcomes.
a. Each step of the nursing process must be exam-
ined to determine what contributed to the failure
to achieve expected goals/outcomes. For example,
the nurse must ask important questions such as:
(1) Was the data cluster thorough and accurate?
(2) Was the nursing diagnosis, problem, or
need identified correctly?
(3) Was the goal realistic and attainable?
(4) Were the expected outcomes specific and
measurable?
(5) Did the planned interventions address all
the etiological factors of the problem?
(6) Were the nursing interventions consis-
tently implemented as planned?
b. The specific reason for not achieving a goal/
expected outcome should be identified. A
variety of reasons may have influenced the
nonachievement of a goal/expected outcome.
For example, the client might not have shared
important information, the staff might not have
completed all tasks as planned, the client might
not have been motivated to participate ade-
quately in the planned care, or the client’s
condition may have changed.
D. Modifying the plan of care
1. Plans of care are dynamic and require modification
to keep them current and relevant.
2. The plan of care must be modified as soon as a
nurse identifies that a plan of care is ineffective.
3. The plan will have to be modified when an ex-
pected goal/outcome is met. Goals and expected
outcomes advance to address evolving needs as the
client moves toward health on the health-illness
continuum.
4. Once a new plan of care is implemented, the step
of evaluation beings again.
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148 Unit 2 Essential Nursing Care Concepts
CASE STUDY: Put ting It All Together
A primary nurse is admitting an older adult to a surgical
unit before surgery for prostate cancer. The primary
health-care provider tells the nurse that the client was
admitted early to ensure that the client is well hy-
drated and that electrolytes are within the expected
range in preparation for surgery. The nurse assesses the
client and collects the following information:
a. Skin is pale, dry, warm, intact, and tenting when
pinched.
b. Capillary refill is delayed and nailbeds are pale.
c. Vital signs: apical pulse 95 beats/min, respirations
23 breaths/min with a slight expiratory wheeze;
temperature 97.8°F using a temporal scanner ther-
mometer (infrared sensor), and blood pressure
160/86 mm Hg.
d. Vesicular breath sounds are present.
e. Hyperactive bowel sounds are present.
f. Slight abdominal distention is present over the
suprapubic area.
g. Tympany is noted on percussion of the abdomen.
h. No lower extremity edema is present.
i. Speech is rapid and at times tremulous.
j. Client appears clean and well groomed, with an
absence of body and breath odor.
When the nurse interviews the client, the client’s
wife remains at the bedside at the client’s request.
The nurse documents the following information on
the nursing admission history and physical:
Case Study Questions
A. Identify the objective data collected by the nurse.
1.
2.
3.
4.
5.
6.
7.
The client told the nurse, “I’ve been taking Hytrin
2 mg at bedtime for the past six months because I was
getting up so many times at night to urinate. I started to
feel bloated and uncomfortable in the abdominal area
several weeks ago and did not feel that I completely
emptied my bladder after urinating. I finally went to
the doctor, who ran tests and said I have prostate
cancer.” The client explained that his doctor then
referred him to a urologist, who planned to do a
total prostatectomy in the morning. The client stated,
“Sometimes I need to go to the bathroom and I don’t
make it in time and I wet myself. It’s embarrassing and I
feel terrible. I’m afraid that I might become impotent
and have incontinence after the surgery, but I trust the
urologist and recognized that the surgery is necessary.”
The client asked many questions about what he can
expect after surgery, which were answered. He said,
“Having cancer puts a big monkey wrench into my
retirement plans. I hope I’ll live long enough to do a
little traveling.” The wife stated, “I don’t care if we can’t
travel. I don’t want him to die. Also, he forgot to tell
you that he is always tired because he keeps getting
up at night to go to the bathroom.” During the inter-
view, the client went to the bathroom and voided
200 mL of dark amber urine. A urine specimen was
sent to the laboratory for a urinalysis. After the inter-
view, the nurse obtained a drug handbook and reviewed
the side effects of Hytrin.
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Chapter 6 Critical Thinking and the Nursing Process 149

CASE STUDY: Put ting It All Together cont ’d

Case Study Questions

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

1.

2.

3.

4.

5.

6.

7.

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

1.

2.

3.

4.