Have you ever observed a nurse seamlessly transition into caring for a patient, armed only with a quick report? It’s a common scenario in healthcare, yet it speaks volumes about the critical thinking and structured approach nurses employ daily. This ability stems from the nursing process, a systematic framework that serves as a roadmap for nurses. It guides their actions and interventions, ensuring patient well-being and optimal health outcomes.
This article delves into the nursing process, emphasizing its role as a cornerstone of professional nursing practice. We will explore how it facilitates safe, patient-centered care, with a particular focus on nursing diagnosis care plans, essential tools in this process.
Core Concepts: Critical Thinking and Clinical Reasoning in Nursing
Before diving into the specifics of the nursing process, it’s vital to understand the cognitive foundations that underpin it: critical thinking and clinical reasoning.
Critical Thinking: The Nurse’s Cognitive Toolkit
Critical thinking in nursing is more than just following protocols; it’s a broad, encompassing skill that involves “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[^1] It’s about proactively ensuring patient safety, validating information, and tailoring care plans based on individual needs, current best practices, and research.
Effective critical thinkers in nursing cultivate specific attitudes that promote rational thought:
- Independence of Thought: Formulating your own judgments and not blindly accepting information.
- Fair-mindedness: Evaluating all perspectives objectively and without prejudice.
- Insight into Egocentricity and Sociocentricity: Recognizing personal biases and prioritizing the patient’s and societal well-being over self-interest.
- Intellectual Humility: Acknowledging the limits of one’s knowledge and expertise.
- Nonjudgmental Attitude: Applying professional ethics rather than personal biases when making decisions.
- Integrity: Upholding honesty and strong moral principles in practice.
- Perseverance: Continuing to seek solutions despite challenges.
- Confidence: Trusting in one’s ability to provide competent care.
- Interest in Exploring Thoughts and Feelings: Being open to different ways of knowing and understanding patient experiences.
- Curiosity: Asking “why” and seeking deeper understanding of patient conditions and situations.
Clinical Reasoning: Analyzing and Acting on Patient Data
Clinical reasoning is defined as “a complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.”[^2] It’s the bridge between data collection and informed decision-making. Nurses use clinical reasoning to generate potential solutions, evaluate evidence, and choose the most effective course of action for patient care. This ability grows with experience and a strong knowledge base.
Inductive and Deductive Reasoning: Pathways to Clinical Judgment
Inductive and deductive reasoning are crucial components of critical thinking, guiding nurses in applying clinical judgment within the nursing process.
Inductive reasoning moves from specific observations to broader generalizations and hypotheses. Nurses observe cues – deviations from expected findings that suggest potential patient problems. They then organize these cues into patterns, forming generalizations. A generalization is a judgment derived from collected facts and observations, like piecing together a puzzle. Based on these generalizations, nurses formulate a hypothesis, a proposed explanation for the patient’s situation, addressing the “why” behind the problem. Identifying the “why” is essential for developing effective solutions.
Attentive observation is the foundation of inductive reasoning. Nurses, like detectives (Figure 4.1), must keenly use their senses to gather cues from the patient and their environment. Strong inductive reasoning is vital, especially in emergencies, enabling quick pattern recognition (generalization) and problem identification (hypothesis).
Example of Inductive Reasoning: A nurse notes redness, warmth, and tenderness at a surgical incision site. Recognizing these cues as a pattern indicative of infection, the nurse hypothesizes a surgical site infection. This leads to notifying the provider and obtaining an antibiotic prescription – a direct application of inductive reasoning in nursing.
Deductive reasoning, conversely, is “top-down thinking.” It applies general rules or standards to specific situations. Nurses use established guidelines from Nurse Practice Acts, regulations, professional bodies like the American Nurses Association, and employer policies to guide patient care decisions.
Example of Deductive Reasoning: A hospital policy mandates quiet zones at night to promote patient rest, based on research showing improved recovery with adequate rest (Figure 4.2). Nurses implement this policy by scheduling care to minimize nighttime disruptions. This is deductive reasoning because the policy, a general rule, is applied to all patients.
Clinical judgment, the outcome of critical thinking and clinical reasoning, is defined by the National Council of State Boards of Nursing (NCSBN) as “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.”^3 The NCLEX exam assesses clinical judgment to ensure nurses are competent and safe.
Evidence-based practice (EBP), as defined by the ANA, is “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.”[^4] EBP is integral to sound clinical judgment and effective nursing care.
The Nursing Process: A Systematic Approach to Patient-Centered Care
The nursing process is a systematic, patient-centered, critical thinking model. It’s the practical application of clinical reasoning and judgment in nursing practice. Rooted in the American Nurses Association (ANA) Standards of Professional Nursing Practice,[^5] the nursing process is encapsulated by the mnemonic ADOPIE: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.
This process is dynamic and cyclical (Figure 4.3), constantly adapting to the patient’s evolving health status.
Consider Scenario A for a practical example of the nursing process in action:
Patient Scenario A: Using the Nursing Process[^6]
A hospitalized patient is prescribed Lasix 80mg IV daily for heart failure. During the morning assessment, the nurse records a blood pressure of 98/60, heart rate of 100, respirations of 18, and temperature of 98.7°F. Reviewing the patient’s chart, the nurse notes a baseline blood pressure around 110/70 and heart rate in the 80s. Recognizing these vital sign changes as cues indicating potential fluid imbalance, the nurse hypothesizes dehydration. Further investigation reveals a 4-pound weight loss since the previous day and patient reports of dry mouth and lightheadedness. Using clinical judgment, the nurse identifies the nursing diagnosis of Fluid Volume Deficit. The nurse then establishes outcomes focused on restoring fluid balance, withholds the Lasix, and contacts the provider to discuss the patient’s condition. Subsequently, the nurse implements interventions to increase oral fluid intake and closely monitors hydration. By shift end, the patient’s fluid balance is evaluated as restored.
In this scenario, the nurse’s actions demonstrate clinical judgment overriding a routine medication order. By assessing, recognizing cues, hypothesizing, planning, implementing, and evaluating, the nurse ensured patient safety and optimized care.
Each component of the nursing process aligns with specific ANA Standards of Professional Nursing Practice, detailed below.
1. Assessment: Gathering Patient Data
The “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.”[^7] This involves a systematic collection and analysis of comprehensive patient data – physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors. For instance, assessing a patient in pain goes beyond just the pain score; it includes observing their responses like mobility limitations, appetite changes, social withdrawal, or emotional distress.[^8]
Assessment involves collecting both subjective and objective data from various sources.
Subjective Data: The Patient’s Perspective
Subjective data is information reported by the patient and/or family, offering valuable insights into their experiences. Documenting subjective data involves using quotation marks and phrases like, “The patient reports…” Building rapport is crucial for obtaining accurate subjective data, particularly regarding emotional, mental, and spiritual well-being.
Subjective data can be primary (directly from the patient) or secondary (from family, charts, or other sources). Patients are the primary source, offering firsthand accounts of their symptoms and feelings. Secondary data is especially important for patients who cannot communicate for themselves, such as infants, children, or individuals with cognitive impairments.
Example of Subjective Data Documentation: “The patient reports, ‘My pain is a level 2 on a 1-10 scale.’”
Objective Data: Observable and Measurable Information
Objective data is observable and measurable through the nurse’s senses – sight, hearing, smell, and touch. It’s reproducible and verifiable by another observer. Examples include vital signs, physical examination findings, and lab results. (Figure 4.6)
Example of Objective Data Documentation: “The patient’s radial pulse is 58 and regular, and their skin feels warm and dry.”
Sources of Assessment Data
Assessment data is gathered through:
- Interview: Asking questions, active listening, and observing verbal and nonverbal cues. Reviewing the patient chart beforehand helps focus the interview. Start with questions related to the patient’s medical diagnoses and their impact on their life. Pay attention to both verbal and nonverbal communication, and validate any inferences.
- Physical Examination: A systematic head-to-toe examination using inspection, auscultation, palpation, and percussion. Inspection involves observation; auscultation involves listening to body sounds with a stethoscope; palpation uses touch to assess organs; and percussion, typically by advanced practitioners, involves tapping body parts to assess size and fluid presence. Vital signs are also part of the physical exam. RNs perform the initial comprehensive assessment, while LPNs/LVNs and UAPs may collect follow-up data under RN supervision.
- Review of Laboratory and Diagnostic Test Results: Provides crucial objective data. Nurses must understand normal and abnormal results and their implications for patient care. Abnormal results necessitate provider notification and prescription verification before implementation.
Types of Nursing Assessments
Different types of assessments are employed in practice:
- Primary Survey: Rapid assessment of level of consciousness, airway, breathing, and circulation (ABCs) in every patient encounter, with immediate intervention for critical issues.
- Admission Assessment: Comprehensive assessment upon admission to a facility, gathering extensive data systematically.
- Ongoing Assessment: Regular head-to-toe assessments in acute care settings, typically every shift, with reporting of changes to the provider.
- Focused Assessment: In-depth assessment of a specific problem or condition.
- Time-lapsed Reassessment: Periodic reassessment in long-term care, usually every three months, to evaluate progress on established outcomes.[^9]
Scenario C integrates these assessment concepts:
Scenario C[^10]
Ms. J., 74, is admitted for shortness of breath, increased ankle and calf swelling, and fatigue. Her history includes hypertension (30 years), coronary artery disease (18 years), heart failure (2 years), and type 2 diabetes (14 years). Medications: aspirin 81 mg daily, metoprolol 50 mg BID, furosemide 40 mg daily, metformin 2000 mg daily.
Admission vital signs: BP 162/96 mmHg, HR 88 bpm, SpO2 91% on room air, RR 28 breaths/min, Temp 97.8°F oral. Weight is up 10 lbs in 3 weeks. Patient states, “I am so short of breath,” “My ankles are so swollen I have to wear my house slippers,” “I am so tired and weak I can’t get out of the house,” and “Sometimes I’m afraid to get out of bed because I get so dizzy.” She expresses a desire to learn more about her health.
Physical exam findings: bilateral basilar crackles, 2+ pitting edema ankles and feet. Labs: serum potassium 3.4 mEq/L (low).
Patient’s daughter adds, “We are so worried about mom living at home alone when she is so tired!”
Critical Thinking Questions:
- Identify subjective data.
- Identify objective data.
- Provide an example of secondary data.
Answers are available at the end of this article.
2. Diagnosis: Identifying Nursing Diagnoses
The “Diagnosis” Standard of Practice states: “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.”[^11] Nursing diagnoses are clinical judgments about a patient’s responses to actual or potential health conditions, forming the basis for care plans and distinct from medical diagnoses.[^12]
Analyzing Assessment Data for Nursing Diagnoses
After assessment, nurses analyze data to identify patterns and formulate nursing diagnoses. This involves data analysis, clustering, hypothesis generation, further assessment (if needed), and formulating diagnostic statements. Prioritized nursing diagnoses then drive the care plan.[^13]
Data Analysis and Clustering
Nurses analyze collected data using their nursing knowledge to determine if findings are expected or unexpected, normal or abnormal, considering the patient’s age, development, and baseline status. They then identify clinically relevant cues for prioritizing care.[^14]
Example: In Scenario C, elevated blood pressure, respiratory rate, decreased oxygen saturation, and low potassium are identified as relevant cues.
After identifying relevant cues, nurses cluster data into patterns, often using frameworks like Gordon’s Functional Health Patterns.[^15] This framework helps organize information based on evidence-based human response patterns. (See box below for an outline.)
Example: In Scenario C, cues like elevated BP, RR, lung crackles, edema, weight gain, shortness of breath, heart failure history, and diuretic use cluster into a pattern of fluid balance issues, aligning with Gordon’s Nutritional-Metabolic pattern. The nurse hypothesizes Excess Fluid Volume.
Gordon’s Functional Health Patterns[^16]
- Health Perception-Health Management: Patient’s perception of health and well-being and management practices.
- Nutritional-Metabolic: Food and fluid intake in relation to metabolic needs.
- Elimination: Bowel, bladder, and skin excretory function.
- Activity-Exercise: Exercise patterns and daily activities.
- Sleep-Rest: Sleep, rest, and relaxation patterns.
- Cognitive-Perceptual: Sensory and cognitive function.
- Self-perception and Self-concept: Self-esteem, body image, and mood.
- Role-Relationship: Role engagements and relationships.
- Sexuality-Reproductive: Reproduction and sexual satisfaction.
- Coping-Stress Tolerance: Stress management and coping mechanisms.
- Value-Belief: Values, beliefs (including spiritual), and guiding life principles.
Identifying Nursing Diagnoses: NANDA-I Framework
Once data is analyzed and clustered, nurses determine the appropriate nursing diagnoses, which are “clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.”[^17] These diagnoses are individualized and guide care plan development. Nurses use resources like care planning guides and NANDA International (NANDA-I) to select accurate diagnoses.
NANDA-I, a global nursing organization, develops and updates standardized nursing terminology for human responses to health problems.[^18] Their list of over 220 diagnoses is continuously refined based on research. (See Appendix A for common diagnoses and consult a care plan reference for a full list.)
NANDA-I diagnoses are categorized into 13 domains similar to Gordon’s Functional Health Patterns, facilitating diagnosis selection based on data patterns. These domains include: Health Promotion, Nutrition, Elimination and Exchange, Activity/Rest, Perception/Cognition, Self-Perception, Role Relationship, Sexuality, Coping/Stress Tolerance, Life Principles, Safety/Protection, Comfort, and Growth/Development.
Note: While specific NANDA-I diagnoses are not tested on the NCLEX, the underlying skills of cue analysis and hypothesis generation are crucial for clinical judgment assessment.
Nursing Diagnoses vs. Medical Diagnoses: A Key Distinction
It’s crucial to differentiate between nursing diagnoses and medical diagnoses. Medical diagnoses, made by physicians or advanced practitioners, focus on diseases or medical conditions. Nursing diagnoses, made independently by RNs, focus on the patient’s response to these conditions and life processes.[^19] Patients with the same medical diagnosis can have different nursing diagnoses due to varied responses. For example, two patients with heart failure may have different nursing diagnoses based on their individual coping mechanisms and learning needs. Nursing diagnoses consider the patient and family’s holistic needs when creating individualized care plans.
Example: In Scenario C, heart failure is a medical diagnosis. It cannot be a nursing diagnosis, but it’s an “associated condition” informing nursing diagnosis hypotheses. The nursing diagnosis will address the patient’s response to heart failure.
NANDA-I Terminology: Patient, Age, and Time
NANDA-I uses specific definitions for terms related to diagnoses:
Patient includes:
- Individual: A single person.
- Caregiver: Family or helper providing regular care.
- Family: Two or more people with sustained relationships and mutual obligations.
- Group: People sharing characteristics (e.g., ethnic group).
- Community: People in a shared locale under common governance.
Age categories:
- Fetus: Unborn human > 8 weeks post-conception to birth.
- Neonate: Person < 28 days old.
- Infant: Person > 28 days and < 1 year old.
- Child: Person aged 1-9 years.
- Adolescent: Person aged 10-19 years.
- Adult: Person > 19 years (or earlier if legally defined).
- Older adult: Person > 65 years.
Time classifications for diagnosis duration:
- Acute: < 3 months.
- Chronic: > 3 months.
- Intermittent: Starts and stops at intervals.
- Continuous: Uninterrupted.
2018-2020 NANDA-I Updates: At-Risk Populations and Associated Conditions
The 2018-2020 NANDA-I edition introduced “at-risk populations” and “associated conditions” to refine diagnoses.[^20]
At-Risk Populations are groups sharing characteristics increasing susceptibility to certain human responses (e.g., demographics, health history).
Associated Conditions are medical diagnoses, injuries, or treatments that, while not nurse-modifiable, provide context for accurate nursing diagnoses.[^21]
Types of Nursing Diagnoses
NANDA-I identifies four types of nursing diagnoses:[^22]
- Problem-Focused: Addresses an undesirable human response to a health condition. Requires related factors (etiology) and defining characteristics (signs/symptoms).
- Health Promotion-Wellness: Focuses on a patient’s desire to enhance well-being and health potential. Expressed by readiness to improve specific health behaviors.
- Risk: Addresses vulnerability to developing an undesirable response. Supported by risk factors (contributing vulnerabilities). Unlike problem-focused diagnoses, the problem hasn’t yet occurred. Risk diagnoses can be high priority.
- Syndrome: A cluster of nursing diagnoses occurring together and best addressed collectively with similar interventions.
Constructing Nursing Diagnosis Statements: PES Format
NANDA-I recommends a nursing diagnosis statement structure including the nursing diagnosis, related factors, and defining characteristics. Accuracy is validated by clearly linking these components from the patient assessment.[^23]
Creating diagnosis statements is often described as using “PES format.” While the acronym is outdated in NANDA-I terminology, the components remain:
- Problem (P): The nursing diagnosis itself.
- Etiology (E): Related factors, phrased as “related to” (R/T).
- Signs and Symptoms (S): Defining characteristics, phrased as “as manifested by” or “as evidenced by.”
Examples of each type of nursing diagnosis statement follow:
Problem-Focused Nursing Diagnosis Example
Problem (P): Nursing diagnosis
Etiology (E): Related factors
Signs and Symptoms (S): Defining characteristics
Scenario C Example: For Ms. J., data clusters indicate Excess Fluid Volume (NANDA-I definition: “surplus intake and/or retention of fluid”). Related factor: excessive fluid intake.[^24]
- P: Fluid Volume Excess
- E: Related to excessive fluid intake
- S: As manifested by bilateral basilar crackles, 2+ pitting edema, 10-lb weight gain, patient report “My ankles are so swollen.”
Complete Problem-Focused Diagnosis Statement: Fluid Volume Excess related to excessive fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.”
Health-Promotion Nursing Diagnosis Example
Problem (P): Nursing diagnosis
Signs and Symptoms (S): Expressed desire to enhance
Scenario C Example: Ms. J. expresses “I would like to learn more about my health…” indicating Readiness for Enhanced Health Management (NANDA-I definition: “a pattern of regulating and integrating into daily living a therapeutic regimen…which can be strengthened.”).[^25]
- P: Readiness for Enhanced Health Management
- S: Expressed desire to “learn more about my health…”
Complete Health-Promotion Diagnosis Statement: Enhanced Readiness for Health Promotion as manifested by expressed desire to “learn more about my health so I can take better care of myself.”
Risk Nursing Diagnosis Example
Problem (P): Nursing diagnosis
As Evidenced By: Risk factors
Scenario C Example: Ms. J.’s dizziness and weakness indicate Risk for Falls (NANDA-I definition: “increased susceptibility to falling, which may cause physical harm…”).[^26]
- P: Risk for Falls
- As Evidenced By: Dizziness and decreased lower extremity strength
Complete Risk Diagnosis Statement: Risk for Falls as evidenced by dizziness and decreased lower extremity strength.
Syndrome Nursing Diagnosis Example
Problem (P): Syndrome
Signs and Symptoms (S): Two or more nursing diagnoses as defining characteristics
Scenario C Example: Ms. J.’s Activity Intolerance (“insufficient energy…to endure daily activities”) and Social Isolation (“aloneness…perceived as imposed…negative state”) can be grouped under Risk for Frail Elderly Syndrome (NANDA-I definition: “dynamic state of unstable equilibrium…deterioration in one or more health domains…increased susceptibility to adverse health effects…”).[^27]
- P: Risk for Frail Elderly Syndrome
- S: Activity Intolerance and Social Isolation
- Related Factor (optional): Fear of falling
Complete Syndrome Diagnosis Statement: Risk for Frail Elderly Syndrome related to activity intolerance, social isolation, and fear of falling.
Prioritization of Nursing Diagnoses
After diagnosis identification, prioritization is crucial. Prioritization determines the most significant nursing problems and interventions in the care plan. Life-threatening issues require immediate attention. Prioritization can be rapid in crises, using clinical judgment swiftly. Most situations fall between crisis and routine care.
Prioritization frameworks include Maslow’s Hierarchy of Needs, ABCs (Airway, Breathing, Circulation), and considering acute vs. chronic conditions. (Figure 4.7)
Maslow’s Hierarchy of Needs categorizes needs by urgency, with physiological needs and safety at the base (highest priority). (Figure 4.8)
While ABCs are vital, safety context matters. In a car crash scenario, safety (removing from danger) precedes immediate airway management.
Acute, uncompensated conditions generally take priority over chronic ones. Actual problems usually precede potential problems, but risk diagnoses can be prioritized based on patient vulnerability.
Example: In Scenario C, the identified diagnoses are Fluid Volume Excess, Enhanced Readiness for Health Promotion, Risk for Falls, and Risk for Frail Elderly Syndrome. Fluid Volume Excess is the highest priority due to its impact on physiological needs (breathing, homeostasis). Risk for Falls is a close second due to safety implications.
3. Outcome Identification: Setting Goals and Expected Outcomes
“Outcome Identification,” the third nursing process step, is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.”[^28] This involves setting measurable goals in collaboration with the patient and healthcare team, documented with timeframes for achievement.
An outcome is a “measurable behavior demonstrated by the patient responsive to nursing interventions.”[^29] Outcomes are set before planning interventions and evaluated after implementation.
Outcome identification involves setting short- and long-term goals and creating specific, measurable outcome statements for each nursing diagnosis.
Short-Term and Long-Term Goals: Patient-Centered Approach
Nursing care must be individualized and patient-centered. Goals and outcomes should be tailored to each patient’s unique needs, values, and cultural beliefs. Patient and family involvement in goal setting is essential for promoting awareness, ensuring realistic goals, and motivating participation in the care plan.
Goals are broad statements defining the overall aim of care. They can be short- or long-term, with timeframes varying by care setting. In critical care, short-term goals might be within an 8-hour shift, long-term within 24 hours. In outpatient settings, short-term goals might be monthly, long-term within six months.
A nursing goal is the desired direction of patient progress to resolve the nursing diagnosis, often the opposite of the problem.
Example: For Ms. J.’s Fluid Volume Excess, a broad goal is: “Ms. J. will achieve a state of fluid balance.”
Expected Outcomes: SMART Criteria
While goals are broad, expected outcomes are specific and measurable statements of patient action within a timeframe, responsive to nursing interventions. Resources like the Nursing Outcomes Classification (NOC), with over 330 standardized outcomes linked to NANDA-I diagnoses, can assist in outcome development.[^30]
Outcomes must be patient-centered, developed collaboratively, and individualized. They should start with “The patient will…”, address defining characteristics of the diagnosis, and be achievable with patient cooperation.
SMART criteria ensure effective outcome statements:[^31]
- Specific
- Measurable
- Attainable/Action-oriented
- Relevant/Realistic
- Time-bound
(Figure 4.9)
Specificity
Outcomes should clearly state what needs to be achieved.
- Non-specific: “The patient will increase exercise.”
- Specific: “The patient will participate in a 30-minute daily bicycling session.”
Each outcome should address only one action for clear evaluation.
- Combined (unclear): “The patient will walk 50 feet TID with standby assist and shower daily until discharge.” (Two outcomes combined)
- Revised (separate): “The patient will walk 50 feet three times a day with standby assistance until discharge.” and “The patient will shower every morning until discharge.” (Clear, measurable outcomes)
Measurability
Outcomes should have numeric parameters or concrete measures for evaluation, using objective data. Avoid vague terms like “acceptable” or “normal.” (Figure 4.10)
- Non-measurable: “The patient will drink adequate fluids each shift.”
- Measurable: “The patient will drink 24 ounces of fluids during each day shift (0600-1400).”
Action-Oriented and Attainable
Outcomes should specify a patient action, using action verbs. (Figure 4.11)
- Non-action-oriented: “The patient will have increased physical activity.”
- Action-oriented: “The patient will list three aerobic activities they enjoy weekly.”
Relevance and Realism
Outcomes must be realistic given the patient’s condition, values, culture, resources, and potential barriers like health literacy or limited access. Outcomes should be regularly re-evaluated and revised for attainability. Unmet outcomes often stem from unrealistic timeframes or patient capabilities.
- Non-realistic: “The patient will jog one mile daily at program start.”
- Realistic: “The patient will walk ½ mile three times weekly for two weeks.”
Time-Bound
Outcomes must include a timeframe for evaluation, varying from shift-based to daily, weekly, or monthly, depending on the intervention and patient condition. Evaluation against the timeframe guides care plan revision if needed.
- Non-time-bound: “The patient will stop smoking.”
- Time-bound: “The patient will complete the smoking cessation plan by December 12, 2024.”
Scenario C Example: For Ms. J.’s Fluid Volume Excess, a SMART outcome is: “The patient will have clear bilateral lung sounds within the next 24 hours.”
4. Planning: Developing Nursing Interventions
“Planning,” the fourth nursing process step, is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.”[^32] This involves creating an individualized, holistic, evidence-based plan in collaboration with the patient, family, and interprofessional team. The plan is prioritized, documented, and adapted based on ongoing patient assessment.
After outcome identification, nurses plan nursing interventions, evidence-based actions to achieve patient outcomes. Similar to medical prescriptions addressing medical conditions, nursing interventions address nursing diagnoses. Interventions should aim to eliminate or reduce related factors of the diagnoses.[^33] Interventions, goals, and outcomes are documented in the nursing care plan for consistent care across shifts and disciplines.
Selecting Nursing Interventions: Evidence-Based Practice
Resources for selecting evidence-based interventions include agency care planning tools within electronic health records, care planning books, and the Nursing Interventions Classification (NIC) system. NIC, based on research and nursing expertise, categorizes and updates evidence-based interventions.[^34] Nurses use clinical judgment to select the most appropriate interventions for individual patient needs.
Direct and Indirect Care Interventions
Nursing interventions are classified as direct or indirect care. Direct care involves personal patient contact, such as wound care, repositioning, and ambulation. Indirect care is performed away from the patient, like care conferences, documentation, and interprofessional communication.
Classification of Nursing Interventions: Independent, Dependent, Collaborative
Nursing interventions are further categorized as independent, dependent, or collaborative. (Figure 4.12)
Independent Nursing Interventions
Independent nursing interventions are actions nurses can initiate without prescriptions. Examples include monitoring intake/output for fluid imbalance risk or using therapeutic communication for coping with a new diagnosis.
Example: For Ms. J.’s Fluid Volume Excess, an independent intervention is: “The nurse will reposition the patient with dependent edema frequently, every 2 hours.”[^35]
Dependent Nursing Interventions
Dependent nursing interventions require a prescription from an authorized primary health care provider (physician, advanced practice nurse, physician assistant).^36 Medication administration is a dependent intervention. Nurses integrate these interventions into the care plan, linking them to relevant nursing diagnoses.
Example: For Ms. J.’s Fluid Volume Excess, a dependent intervention is: “The nurse will administer scheduled diuretics as prescribed.”
Collaborative Nursing Interventions
Collaborative nursing interventions are carried out with other healthcare team members (physicians, social workers, therapists). These are developed in consultation, incorporating diverse professional perspectives.[^37]
Example: For Ms. J.’s Fluid Volume Excess, a collaborative intervention is: “The nurse will manage oxygen therapy in collaboration with the respiratory therapist” for deteriorating oxygen saturation.
Individualization of Interventions
Interventions must be individualized to be effective. For instance, suggesting prune juice for constipation is only effective if the patient likes prune juice. Patient, family, and interprofessional team collaboration is crucial for selecting effective, personalized interventions.
Nursing Care Plans: Documentation and Legal Requirements
Nursing care plans, created by RNs, are legally required in long-term care facilities by CMS and in hospitals by The Joint Commission.[^38, ^39] CMS emphasizes patient participation in care planning, including treatment decisions and refusals. The Joint Commission views care plans as a communication framework for safe and effective care coordination.
Many facilities use standardized care plans with customizable intervention lists. Others require fully independent care plan development. Regardless of format, care plans must be individualized. (Figure 4.13)
Nursing school care plans can vary in format, from concept maps to tables. Appendix B provides a template for creating nursing care plans.
5. Implementation: Putting the Plan into Action
“Implementation,” the fifth nursing process step, is defined as, “The registered nurse implements the identified plan.”[^40] This involves the RN using critical thinking and clinical judgment to carry out the planned interventions. Continual patient reassessment is crucial during implementation to adapt the plan to changing conditions. RNs may delegate interventions to LPNs or UAPs while retaining accountability.
Implementation includes prioritizing interventions, ensuring patient safety, delegating appropriately, and documenting actions.
Prioritizing Intervention Implementation
Prioritization follows similar principles as diagnosis prioritization, using Maslow’s Hierarchy and ABCs. Less invasive actions are generally preferred initially. Consider the impact of timely task completion on future events. For example, NPO orders before surgery take priority. Understanding the patient’s care purpose and expected outcomes is key for accurate prioritization.
Patient Safety During Implementation
Patient safety is paramount during intervention implementation. Changes in patient condition may make planned interventions unsafe. For example, a patient feeling dizzy may not be ambulated as planned, despite it being in the care plan. Such decisions, with supporting assessments, must be documented and communicated to the healthcare team and provider.
Nurses, as frontline providers, are crucial for error prevention.[^41] Landmark reports like the Institute of Medicine’s “To Err Is Human” and “Preventing Medication Errors” highlighted the prevalence of preventable medical errors and medication errors in healthcare, emphasizing the need for system improvements and vigilance.[^42, ^43]
Errors involving nurses can range from wrong-site surgeries and medication errors to failures in infection control and fall prevention.[^44] Contributing factors include nurse fatigue from long shifts, flawed systems lacking safety checks, and interruptions during care delivery.
The Quality and Safety Education for Nurses (QSEN) project aims to prepare nurses to continuously improve healthcare quality and safety.[^45] Nurses are expected to participate in quality improvement (QI) initiatives to identify and address gaps in care.[^46]
Delegation of Nursing Interventions
RNs may delegate tasks to LPNs or UAPs, retaining accountability for outcomes.[^47] Delegation requires considering patient condition, task complexity, communication, supervision, and the Nurse Practice Act and agency policies. RNs cannot delegate tasks requiring clinical judgment.[^48]
See box for Wisconsin Nurse Practice Act delegation guidelines.
Delegation According to the Wisconsin Nurse Practice Act[^49]
During supervision of delegated acts, an RN must:
a. Delegate tasks appropriate to the supervisee’s education and abilities.
b. Provide direction and assistance.
c. Observe and monitor activities.
d. Evaluate effectiveness of supervised actions.
Wisconsin LPN standard of practice:[^50]
In basic patient situations under RN supervision, LPNs shall:
a. Accept assignments within their competence.
b. Provide basic nursing care (predictable patient responses to defined procedures).
c. Record care and report patient condition changes.
d. Consult providers if delegated acts may harm patients.
e. Perform tasks including: data collection assistance, care plan contribution, reinforcing RN teaching, basic health instruction, and participating in meeting basic patient needs.
Refer to Wisconsin’s Nurse Practice Act Chapter N 6 for detailed RN/LPN scope of practice and ANA’s Principles of Delegation.
Table 4.7 provides general delegation guidelines in Wisconsin.
Documentation of Implemented Interventions
Timely documentation of interventions is crucial. Lack of documentation is legally considered a failure to act. Documenting medication administration and other interventions promptly prevents errors and ensures accurate records.
Coordination of Care and Health Teaching/Health Promotion
ANA Implementation Standards include Coordination of Care and Health Teaching and Health Promotion.[^51] Coordination involves plan organization, patient self-care engagement, and advocating for holistic care. Health teaching includes strategies for health and wellness promotion, a key component of every patient encounter, from medication education to self-management strategies.
Scenario C Implementation Example:
In Scenario C, interventions prioritized breathing. Diuretic administration was prioritized, with frequent lung sound monitoring. Weighing the patient was delegated to the CNA. Patient education on medications and edema management was provided. All interventions were documented in the EMR.
6. Evaluation: Assessing Outcome Achievement and Care Plan Effectiveness
“Evaluation,” the final nursing process step, is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.”[^52] This involves ongoing assessment of patient status and care plan effectiveness, with modifications as needed.
Evaluation focuses on determining if expected outcomes were met within specified timeframes. Nurses use critical thinking to analyze reassessment data and categorize outcome achievement as met, partially met, or not met. Unmet or partially met outcomes necessitate care plan revision, with reassessment occurring continuously. Care plans should adapt to emerging priorities. Evaluation results must be documented.
If outcomes are not met, consider these questions for care plan revision:
- Were there unanticipated events?
- Has the patient’s condition changed?
- Were outcomes and timeframes realistic?
- Are nursing diagnoses still accurate?
- Are interventions effectively supporting outcome attainment?
- What barriers were encountered during implementation?
- Does reassessment data suggest revisions to diagnoses, outcomes, interventions, or implementation?
- Are different interventions needed?
Scenario C Evaluation Example:
For Ms. J.’s Fluid Volume Excess, outcomes were:
- Report decreased dyspnea within 8 hours.
- Clear lung sounds within 24 hours.
- Decreased edema within 24 hours.
- Weight return to baseline by discharge.
Day 1 evaluation: “Patient reported decreased shortness of breath, lungs clear in lower bases. Weight down 1 kg, 2+ edema persists in ankles/calves.” Outcomes evaluated as “Partially Met.” Care plan revised with new interventions:
- Request TED hose prescription.
- Elevate legs when sitting.
For Risk for Falls, outcome “Patient verbalizes understanding and calls for assistance. No falls occurred” was evaluated as “Met.”
Ongoing reassessment and care plan revision continue throughout hospitalization, with all evaluations documented in the medical record.
Summary: The Nursing Process as a Framework for Excellence
The nursing process, encompassing Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation (ADOPIE), provides a structured approach to patient-centered care. It relies on critical thinking, clinical reasoning, and judgment at each step. Continuous reassessment and care plan adjustments are vital for achieving patient outcomes. The patient remains central throughout, ensuring individualized, effective, and safe professional nursing practice.
Video Review of Creating a Sample Care Plan^53
Learning Activities
Learning Activities
(Answers are available in the “Answer Key” at the end of this article.)
Instructions: Create a nursing care plan for Mark S., using the template in Appendix B as a guide.
Mark S., 57, is hospitalized with “severe” abdominal pain, scheduled for diagnostic tests. He paces constantly, repeats questions about test duration, and says, “I’m so uptight I will never be able to sleep.” He avoids eye contact, fidgets, and appears tense with strained expression, stating “My mouth is so dry.” Vital signs: T 98°F, HR 104 bpm, RR 30 breaths/min, BP 180/96 mmHg. Skin is diaphoretic and cool.
Critical Thinking Activity:
- Cluster subjective and objective data.
- Create a problem-focused nursing diagnosis.
- Develop a broad goal and a SMART outcome.
- Outline three evidence-based interventions. Cite a source.
- Evaluate outcome achievement: Met – Partially Met – Not Met.
Glossary of Key Terms
Advocacy: Supporting or recommending a cause or action.[^54]
Art of nursing: Compassionate, comforting care with unconditional acceptance of patient humanity and dignity.[^55]
At-risk populations: Groups susceptible to specific human responses due to shared characteristics.[^56]
Associated conditions: Medical diagnoses or treatments influencing nursing diagnoses but not nurse-modifiable.[^57]
Basic nursing care: Predictable care following defined procedures with minimal modification.[^58]
Caring relationship: Relationship balancing patient vulnerability and dignity, assessing the whole person.[^59]
Client: Individual, family, group, or community receiving care.^60
Clinical judgment: Outcome of critical thinking and decision-making, using nursing knowledge for safe care delivery.^61
Clinical reasoning: Cognitive process analyzing patient data and weighing actions.[^62]
Clustering data: Grouping data into similar patterns.
Collaborative nursing interventions: Interventions requiring interprofessional cooperation.
Coordination of care: Plan organization, patient self-care engagement, and advocating for holistic care.[^63]
Critical thinking: Reasoning about clinical issues, including teamwork and workflow.[^64]
Cue: Hint or indication of a potential problem.
Deductive reasoning: “Top-down” thinking, applying general rules to specific situations.
Defining characteristics: Observable cues manifesting a nursing diagnosis.[^65]
Delegation: Assigning tasks to UAPs or LPNs while retaining accountability.[^66]
Dependent nursing interventions: Interventions requiring a provider prescription.
Direct care: Interventions involving personal patient contact.
Electronic Medical Record (EMR): Digital patient medical chart.
Evidence-Based Practice (EBP): Problem-solving integrating research, expertise, and patient values.[^67]
Expected outcomes: Measurable patient actions within a timeframe, responsive to interventions. SMART outcomes are specific, measurable, action-oriented, realistic, and time-bound.[^68]
Functional health patterns: Assessment framework for identifying patient problems.
Generalization: Judgment formed from facts and observations.
Goals: Broad statements of care purpose.
Health teaching and health promotion: Strategies to teach and promote wellness.[^69]
Independent nursing interventions: Interventions nurses initiate without prescriptions.
Indirect care: Interventions performed away from direct patient contact.
Inductive reasoning: Generalizations from specific instances.
Inference: Interpretations based on cues or assumptions.
Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs): Licensed nurses with specific training, scope defined by state and facility.^70
Medical diagnosis: Disease or illness identified by a physician or advanced practitioner.
Nursing: Integration of art and science of caring, focusing on health promotion, illness prevention, and human responses.[^71]
Nursing care plan: Documentation of planned and delivered nursing care, required by regulatory bodies.[^72]
Nursing process: Systematic patient-centered care approach: ADOPIE (Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, Evaluation).[^73]
Objective data: Observable and measurable data.
Outcome: Measurable patient behavior responsive to interventions.[^74]
PES Statement: Nursing diagnosis statement format: Problem, Etiology, Signs/Symptoms.
Prescription: Provider-ordered interventions or treatments.^75
Primary data: Information directly from the patient.
Primary health care provider: Licensed professional authorized to prescribe care.^76
Prioritization: Deciding action order for optimal patient outcomes and safety.
Quality improvement: Continuous efforts to improve health, care, and professional development.[^77]
Rapport: Mutual trust and understanding in a relationship.
Registered Nurse (RN): Licensed nurse with designated education and training.
Related factors: Underlying causes (etiology) of a nursing diagnosis.
Right to self-determination: Patient autonomy in healthcare decisions.
Scientific method: Knowledge discovery through problem formulation, data collection, and hypothesis testing.
Secondary data: Information from sources other than the patient.
Subjective data: Patient-reported or nurse-inferred data.
Unlicensed Assistive Personnel (UAP): Trained unlicensed personnel in supportive roles.^78
[^1]: Klenke-Borgmann L., Cantrell M. A., Mariani B. Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives. 2020;41(4):215–221.
[^2]: Klenke-Borgmann L., Cantrell M. A., Mariani B. Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives. 2020;41(4):215–221.
[^4]: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
[^5]: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
[^6]: “Patient Image in LTC.JPG” by ARISE project is licensed under CC BY 4.0
[^7]: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
[^8]: American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/
[^9]: Gordon, M. (2008). Assess notes: Nursing assessment and diagnostic reasoning. F.A. Davis Company.
[^10]: “grandmother-1546855_960_720.jpg” by vendie4u is licensed under CC0
[^11]: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
[^12]: American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/
[^13]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^14]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^15]: Gordon, M. (2008). Assess notes: Nursing assessment and diagnostic reasoning. F.A. Davis Company.
[^16]: Gordon, M. (2008). Assess notes: Nursing assessment and diagnostic reasoning. F.A. Davis Company.
[^17]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^18]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^19]: American Nurses Association. (n.d.). The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/
[^20]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^21]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^22]: NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/
[^23]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^24]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^25]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^26]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^27]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^28]: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
[^29]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^30]: Johnson, M., Moorhead, S., Bulechek, G., Butcher, H., Maas, M., & Swanson, E. (2012). NOC and NIC linkages to NANDA-I and clinical conditions: Supporting critical reasoning and quality care. Elsevier.
[^31]: Campbell, J. (2020). SMART criteria. Salem Press Encyclopedia.
[^32]: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
[^33]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^34]: Butcher, H. K., Bulechek, G. M., Dochterman, J. M., & Wagner, C. M. (2018). Nursing interventions classifications (NIC) (7th ed.). Elsevier.
[^35]: Butcher, H. K., Bulechek, G. M., Dochterman, J. M., & Wagner, C. M. (2018). Nursing interventions classifications (NIC) (7th ed.). Elsevier.
[^37]: Vera, M. (2020). Nursing care plan (NCP): Ultimate guide and database. https://nurseslabs.com/nursing-care-plans/#:~:text=Collaborative%20interventions%20are%20actions%20that,to%20gain%20their%20professional%20viewpoint.
[^38]: Centers for Medicare and Medicaid Services. (2017). State operations manual: Appendix PP – Guidance to surveyors for long term care facilities. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
[^39]: The Joint Commission (n.d.). Standards and guides pertinent to nursing practice. https://www.jointcommission.org/resources/for-nurses/nursing-resources/
[^40]: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
[^41]: Robert Wood Johnson Foundation. (2011, April 28). Nurses are key to improving patient safety. https://www.rwjf.org/en/library/articles-and-news/2011/04/nurses-are-key-to-improving-patient-safety.html
[^42]: Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. National Academies Press. https://pubmed.ncbi.nlm.nih.gov/25077248/
[^43]: Institute of Medicine. (2007). Preventing medication errors. National Academies Press. 10.17226/11623.
[^44]: Robert Wood Johnson Foundation. (2011, April 28). Nurses are key to improving patient safety. https://www.rwjf.org/en/library/articles-and-news/2011/04/nurses-are-key-to-improving-patient-safety.html
[^45]: QSEN Institute. (n.d.). Project overview: The evolution of the quality and safety education for nurses (QSEN) initiative. http://qsen.org/about-qsen/project-overview/
[^46]: Batalden P. B., Davidoff F. What is “quality improvement” and how can it transform healthcare?. BMJ Quality & Safety. 2007;16(1):2–3.
[^47]: American Nurses Association. (2013). ANA’s principles for delegation by registered nurses to unlicensed assistive personnel (UAP). American Nurses Association. https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principlesofdelegation.pdf
[^48]: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
[^49]: Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf
[^50]: Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf
[^51]: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
[^52]: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
[^54]: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
[^55]: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
[^56]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^57]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^58]: Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf
[^59]: Walivaara B., Savenstedt S., Axelsson K. Caring relationships in home-based nursing care – registered nurses’ experiences. The Open Journal of Nursing. 2013;7:89–95. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722540/pdf/TONURSJ-7-89.pdf
[^62]: Klenke-Borgmann L., Cantrell M. A., Mariani B. Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives. 2020;41(4):215–221.
[^63]: American Nurses Association. (2021). Nursing: Scope and standards of practice (3rd ed.). American Nurses Association.
[^64]: Klenke-Borgmann L., Cantrell M. A., Mariani B. Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives. 2020;41(4):215–221.
[^65]: NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms
[^66]: American Nurses Association. (2013). ANA’s principles for delegation by registered nurses to unlicensed assistive personnel (UAP). American Nurses Association. https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principlesofdelegation.pdf
[^67]: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
[^68]: Campbell, J. (2020). SMART criteria. Salem Press Encyclopedia.
[^69]: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
[^71]: American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
[^72]: The Joint Commission (n.d.). Standards and guides pertinent to nursing practice. https://www.jointcommission.org/resources/for-nurses/nursing-resources/
[^73]: American Nurses Association. (n.d.) The nursing process. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/
[^74]: Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York.
[^77]: Batalden P. B., Davidoff F. What is “quality improvement” and how can it transform healthcare?. BMJ Quality & Safety. 2007;16(1):2–3.
