Have you ever observed a seasoned nurse seamlessly take over patient care after a quick handover, instantly grasping the patient’s needs and priorities? This proficiency stems from a deep understanding of the nursing process, a critical thinking framework that guides every aspect of patient care. This article delves into the nursing process, with a focus on utilizing NANDA nursing care plans and the NANDA nursing diagnosis list 2018 2020 to enhance patient outcomes in English-speaking healthcare settings. We’ll explore how to leverage these tools to create comprehensive, patient-centered care plans that are both effective and SEO-optimized for professionals seeking guidance in this crucial area of nursing practice.
Understanding the Foundations: Critical Thinking and Clinical Reasoning in Nursing
Before diving into the specifics of NANDA diagnoses and care plans, it’s essential to understand the cognitive processes that underpin effective nursing practice: critical thinking and clinical reasoning.
Critical thinking in nursing goes beyond simply following protocols. It involves a deliberate and reflective approach to patient care, encompassing teamwork, collaboration, and efficient workflow management.[1] A critical thinker in nursing independently validates patient information, bases care plans on individual needs and current best practices, and continuously seeks ways to improve patient safety and outcomes. Key attributes of a critical thinker include:
- Independent Thinking: Forming your own judgments and not blindly accepting information.
- Fairness: Objectively considering all viewpoints without bias.
- Self-awareness: Recognizing personal biases (egocentricity) and acting for the greater good (sociocentricity).
- Intellectual Humility: Acknowledging the limits of one’s knowledge and skills.
- Non-Judgmental Approach: Applying professional ethics rather than personal morals in decision-making.
- Integrity: Maintaining honesty and strong ethical principles.
- Perseverance: Continuing despite challenges.
- Confidence: Trust in one’s ability to perform tasks effectively.
- Openness to Reflection: Exploring different perspectives and approaches.
- Curiosity: Continuously asking “why” and seeking deeper understanding.
Clinical reasoning, closely related to critical thinking, is defined as the “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] Developing strong clinical reasoning skills is a journey built on experience and a solid knowledge base, enabling nurses to make sound judgments in patient care.[3] This process often involves both inductive and deductive reasoning.
Inductive and Deductive Reasoning in Clinical Judgment
Inductive reasoning is a “bottom-up” approach. It starts with observing specific cues – unexpected data or deviations from the norm – and forming generalizations to create hypotheses. Cues are essentially hints that something might be amiss with a patient. Nurses gather these cues, identify patterns, and formulate a generalization, much like assembling pieces of a puzzle. This generalization leads to a hypothesis, a proposed explanation for the patient’s situation, addressing the “why” behind the observed cues. Identifying the “why” is crucial for developing effective solutions.
Figure 4.1
Inductive Reasoning: Looking for Cues
Example of Inductive Reasoning: A nurse notices redness, warmth, and tenderness at a surgical incision site. These cues form a pattern suggestive of infection. The nurse generalizes that these are signs of a potential infection and hypothesizes that the incision is infected. This leads to notifying the provider and obtaining an antibiotic prescription.
Deductive reasoning, conversely, is “top-down” thinking. It applies general rules or standards to specific situations. Nurses utilize established protocols, institutional policies, and professional standards (like those from the ANA or Nurse Practice Acts) to guide their actions and solve patient problems.
Figure 4.2
Deductive Reasoning: Implementing a Quiet Zone Policy
Example of Deductive Reasoning: A hospital implements a “quiet zone” policy based on research showing improved patient recovery with rest. This policy (the general rule) dictates specific actions for nurses (the specific application) to ensure all patients benefit from a quieter nighttime environment, regardless of their individual sleep patterns.
Clinical judgment is the culmination of critical thinking and clinical reasoning, using both inductive and deductive approaches. The National Council of State Boards of Nursing (NCSBN) defines it 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.”[6] Clinical judgment is a core competency assessed in the NCLEX exam, ensuring nurses are prepared for safe and effective practice.
Evidence-based practice (EBP) is integral to clinical judgment. As defined by the American Nurses Association (ANA), EBP 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.”[7]
The Nursing Process: A Systematic Approach to Patient Care
The nursing process is a structured, patient-centered model for critical thinking in nursing. It’s aligned with the American Nurses Association (ANA) Standards of Professional Nursing Practice, which outline the expected actions and behaviors of registered nurses across all roles and settings.[8] The mnemonic ADOPIE helps remember the six steps of the nursing process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.
The nursing process is cyclical and dynamic, constantly adapting to the patient’s evolving health status.
Figure 4.3
The Nursing Process
Scenario A: Applying the Nursing Process
Consider a patient prescribed Lasix 80mg IV daily for heart failure. During morning assessment, the nurse finds a blood pressure of 98/60, heart rate of 100, respirations of 18, and temperature of 98.7F. Reviewing the patient’s chart reveals a baseline blood pressure of around 110/70 and heart rate in the 80s. The nurse recognizes these vital signs as cues suggesting potential fluid imbalance, hypothesizing dehydration. Further assessment reveals a 4-pound weight loss and patient reports of dry mouth and lightheadedness. Using clinical judgment, the nurse makes a nursing diagnosis of Fluid Volume Deficit, setting outcomes for fluid balance restoration. The nurse plans to withhold Lasix, contacts the provider, and implements interventions like encouraging oral intake and monitoring hydration. Evaluation at shift end confirms restored fluid balance.
This scenario highlights the nurse’s critical thinking: not just administering medication blindly, but assessing, interpreting cues, hypothesizing, planning, intervening, and evaluating to ensure patient safety and optimal outcomes.
Let’s examine each component of the nursing process and its corresponding ANA Standard of Professional Practice in detail.
Step 1: Assessment – Gathering Patient Data
The first step, Assessment, as per ANA Standard of Practice, involves the “registered nurse [collecting] pertinent data and information relative to the health care consumer’s health or the situation.”[11] This is a systematic and ongoing process, encompassing physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors. For example, assessing a patient in pain includes not only pain level but also its impact on mobility, appetite, social interaction, and emotional state.[12]
Assessment data can be subjective (patient’s perspective) or objective (nurse’s observations and measurements).
Subjective Data
Subjective data is information provided by the patient or their family, offering crucial insights from their viewpoint. It’s essential to document subjective data in quotation marks, attributing it to the source (e.g., “The patient reports, ‘My pain is sharp.'”). Building rapport is key to obtaining accurate subjective data, especially concerning emotional and spiritual well-being.
Primary data comes directly from the patient, the most reliable source about their feelings and experiences. Secondary data is gathered from other sources like family members, medical records, or previous caregivers, particularly valuable when patients cannot communicate for themselves.
Figure 4.5
Obtaining Subjective Data in a Care Relationship
Example of Subjective Data Documentation: “Patient reports, ‘My anxiety level is 7 out of 10.’”
Objective Data
Objective data is observable and measurable through the nurse’s senses: sight, hearing, touch, and smell. It’s reproducible, meaning another assessor should obtain similar findings. Examples include vital signs, physical exam findings, and lab results.
Figure 4.6
Physical Examination
Example of Objective Data Documentation: “Apical pulse is 72 and regular. Lungs clear to auscultation bilaterally.”
Sources of Assessment Data
Data is collected through interviews, physical examinations, and review of diagnostic results.
Interviewing Patients
Patient interviews involve asking questions, active listening, and observing verbal and nonverbal cues. Reviewing the patient’s chart beforehand helps focus the interview and avoid redundancy. Start by introducing yourself, explaining your role and the interview’s purpose and duration. Inquire about their medical diagnoses and how they impact their life. Active listening and clarifying ambiguities are crucial for uncovering valuable cues. Pay attention to both what is said and unsaid, validating any inferences to avoid misinterpretations.
Physical Examination
A physical examination is a systematic assessment using inspection, auscultation, palpation, and percussion. Inspection is visual observation. Auscultation uses a stethoscope to listen to body sounds. Palpation uses touch to assess organ size, location, and tenderness. Percussion, typically by advanced practitioners, involves tapping body parts to assess density and fluid presence. Physical exams can be comprehensive (head-to-toe) or focused on specific concerns. RNs perform initial comprehensive assessments, while LPNs/LVNs and UAPs may collect follow-up data under RN supervision.
Reviewing Diagnostic Results
Laboratory and diagnostic test results provide essential objective data. Nurses must understand normal and abnormal values and their implications for patient care, verifying prescriptions and notifying providers of concerning results.
Types of Nursing Assessments
- Primary Survey: Rapid assessment of consciousness, airway, breathing, and circulation (ABCs) in emergency situations.
- Admission Assessment: Comprehensive initial assessment upon admission to a healthcare facility.
- Ongoing Assessment: Regular head-to-toe assessments, often shift-based in acute care, to monitor patient status.
- Focused Assessment: In-depth assessment of a specific problem or system.
- Time-lapsed Reassessment: Periodic comprehensive assessments in long-term care to evaluate progress over months. [4]
Scenario C: Putting Assessment Together
Ms. J., 74, admitted with shortness of breath, ankle swelling, and fatigue. History of hypertension, heart disease, heart failure, and diabetes. Medications: aspirin, metoprolol, furosemide, metformin.
Admission Assessment Findings:
- BP: 162/96 mmHg
- HR: 88 bpm
- SpO2: 91% on room air
- RR: 28 breaths/min
- Temp: 97.8°F
- Weight: 10 lbs gain in 3 weeks
- Subjective: “So short of breath,” “Ankles so swollen,” “Tired and weak,” “Afraid to get out of bed,” “Want to learn more.”
- Objective: Bilateral lung crackles, 2+ pitting edema ankles/feet, Potassium 3.4 mEq/L.
- Secondary (Daughter): “Worried about mom living alone.”
Critical Thinking Questions:
- Subjective Data: Patient reports of shortness of breath, swollen ankles, fatigue, dizziness, desire to learn.
- Objective Data: Vital signs (BP, HR, RR, SpO2, Temp), weight gain, lung crackles, edema, potassium level.
- Secondary Data: Daughter’s concern about independent living.
Step 2: Diagnosis – Identifying Nursing Diagnoses
Diagnosis, the second step and ANA Standard, involves the “registered nurse [analyzing] the assessment data to determine actual or potential diagnoses, problems, and issues.”[13] This step is about making a nursing diagnosis, which is distinct from a medical diagnosis. The RN prioritizes these diagnoses to guide the care plan.[1]
Analyzing Data for Nursing Diagnoses
Data analysis involves interpreting assessment findings to identify patterns and potential nursing diagnoses. This includes data analysis, clustering, hypothesis generation, further assessment (if needed), and formulating nursing diagnosis statements.
Data Analysis and Clustering
Nurses analyze collected data, comparing it to expected norms based on age, development, and the patient’s baseline. Relevant cues – unexpected or abnormal data – are identified and prioritized.
Example (Scenario C): Elevated BP, RR, decreased SpO2 are relevant cues.
Clustering Information and Forming Hypotheses
Relevant cues are grouped into patterns, often using frameworks like Gordon’s Functional Health Patterns. This framework organizes data into eleven areas of human function (see box below).
Example (Scenario C): Elevated BP, RR, crackles, edema, weight gain, shortness of breath, heart failure history, diuretic use cluster under “Nutritional-Metabolic” (Fluid Balance), suggesting “Excess Fluid Volume.”
Gordon’s Functional Health Patterns[5]
- Health Perception-Health Management: Patient’s view of health and self-care practices.
- Nutritional-Metabolic: Food and fluid intake and metabolism.
- Elimination: Bowel, bladder, skin excretion.
- Activity-Exercise: Exercise, mobility, and daily activities.
- Sleep-Rest: Sleep patterns, rest, and energy levels.
- Cognitive-Perceptual: Sensory functions, cognition, and pain.
- Self-perception and Self-concept: Self-esteem, body image, and emotional state.
- Role-Relationship: Social roles, relationships, and support systems.
- Sexuality-Reproductive: Sexual health and reproductive function.
- Coping-Stress Tolerance: Stress management and coping mechanisms.
- Value-Belief: Values, beliefs, and spiritual practices.
Identifying NANDA-I Nursing Diagnoses
Once data is analyzed and clustered, the next step is to formulate nursing diagnoses – statements about the patient’s human response to health conditions. A nursing diagnosis is a “clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.”[6]
NANDA International (NANDA-I) is the leading organization for developing and standardizing nursing diagnoses. The NANDA nursing diagnosis list 2018-2020 provided a structured and updated vocabulary for nurses to accurately describe patient problems. This list, continuously revised, contains over 220 diagnoses categorized into 13 domains (similar to Gordon’s Functional Health Patterns), aiding in diagnosis selection. Appendix A provides a list of common NANDA-I diagnoses, and comprehensive references offer the full list.
Nursing Diagnoses vs. Medical Diagnoses
Nursing diagnoses differ from medical diagnoses. Medical diagnoses identify diseases, while nursing diagnoses describe patient responses to health conditions. Patients with the same medical diagnosis can have different nursing diagnoses due to varied individual responses.
Example: Two patients with heart failure (medical diagnosis) might have different nursing diagnoses. One might have “Deficient Knowledge” about their condition, while another experiences “Anxiety” related to their prognosis. Nursing diagnoses are patient-centered, considering individual needs, strengths, and resources for holistic care.
Associated conditions, like medical diagnoses, injuries, or treatments, can provide context for nursing diagnoses but are not nursing diagnoses themselves. In Scenario C, heart failure is an associated condition, not a nursing diagnosis, but informs potential nursing diagnoses related to the patient’s response to heart failure.
NANDA-I Terminology: Patient, Age, and Time
NANDA-I uses specific definitions for terms like “Patient,” “Age,” and “Time” to standardize diagnoses. “Patient” can refer to an individual, caregiver, family, group, or community. Age categories range from fetus to older adult. Time descriptors include acute (<3 months), chronic (>3 months), intermittent, and continuous.
New Terms in 2018-2020 NANDA-I: At-Risk Populations and Associated Conditions
The NANDA nursing diagnosis list 2018 2020 introduced “at-risk populations” and “associated conditions” to refine diagnoses.[11] At-risk populations are groups sharing characteristics increasing susceptibility to specific responses. Associated conditions, as mentioned, are medical diagnoses or treatments providing context.
Types of Nursing Diagnoses
NANDA-I classifies diagnoses into four types:[13]
- Problem-Focused: Describes an existing undesirable response to a health condition. Requires related factors and defining characteristics.
- Health Promotion-Wellness: Describes a desire to enhance well-being. Focuses on readiness to improve health behaviors.
- Risk: Describes vulnerability to developing an undesirable response. Supported by risk factors.
- Syndrome: Clusters of nursing diagnoses occurring together and best addressed collectively.
Constructing Nursing Diagnosis Statements (PES Format)
NANDA-I recommends a structure including the nursing diagnosis, related factors, and defining characteristics. This is often referred to as PES format, though NANDA-I terminology has evolved.
- Problem (P): The nursing diagnosis itself.
- Etiology (E): Related factors, the “causes” of the problem (phrased as “related to”).
- Signs and Symptoms (S): Defining characteristics, the evidence supporting the diagnosis (phrased as “as manifested by” or “as evidenced by”).
Problem-Focused Nursing Diagnosis Example (Scenario C)
Problem (P): Fluid Volume Excess (NANDA-I Diagnosis: “surplus intake and/or retention of fluid”[23])
Etiology (E): Related to excessive fluid intake
Signs and Symptoms (S): As manifested by bilateral basilar crackles, 2+ pitting edema, 10 lb weight gain, patient report of “swollen ankles.”
Full 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 (Scenario C)
Problem (P): Readiness for Enhanced Health Management (NANDA-I Diagnosis: “a pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its sequelae, which can be strengthened”[25])
Signs and Symptoms (S): Expresses desire to “learn more about my health so I can take better care of myself.” (Begins with “expresses desire to enhance”)
Full 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 (Scenario C)
Problem (P): Risk for Falls (NANDA-I Diagnosis: “increased susceptibility to falling, which may cause physical harm and compromise health”[27])
As Evidenced By: Dizziness and decreased lower extremity strength (risk factors)
Full Statement: Risk for Falls as evidenced by dizziness and decreased lower extremity strength.
Syndrome Nursing Diagnosis Example (Scenario C)
Problem (P): Risk for Frail Elderly Syndrome (NANDA-I Syndrome: “dynamic state of unstable equilibrium…deterioration in one or more domains of health…leads to increased susceptibility to adverse health effects”[29])
Signs and Symptoms (S): Activity Intolerance, Social Isolation (defining nursing diagnoses)
Related Factor: Fear of falling (optional, for clarity)
Full Statement: Risk for Frail Elderly Syndrome related to activity intolerance, social isolation, and fear of falling.
Prioritizing Nursing Diagnoses
After identifying diagnoses, prioritization is crucial. Prioritization involves ranking diagnoses based on urgency and patient needs. Life-threatening issues are always addressed first.
Maslow’s Hierarchy of Needs helps prioritize based on basic human needs, with physiological needs and safety at the base. The ABCs (Airway, Breathing, Circulation) are also vital for immediate prioritization. Acute, uncompensated conditions generally take precedence over chronic ones. Actual problems are usually prioritized over risk problems, though risk diagnoses can be high priority depending on patient vulnerability.
Figure 4.7
The How To of Prioritization
Figure 4.8
Maslow’s Hierarchy of Needs
Example (Scenario C): 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 concerns.
Step 3: Outcome Identification – Setting Goals and Outcomes
Outcome Identification, the third step and ANA Standard, is where the “registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.”[15] This involves setting measurable goals in collaboration with the patient and healthcare team.
An outcome is a “measurable behavior demonstrated by the patient responsive to nursing interventions.”[17] Outcomes are established before planning interventions.
Short-Term and Long-Term Goals
Nursing care must be patient-centered and individualized. Goals are broad statements of desired patient status, either short-term or long-term, depending on the care setting. They are often the opposite of the nursing diagnosis.
Example (Scenario C – Fluid Volume Excess): Broad goal: “Ms. J. will achieve a state of fluid balance.”
Expected Outcomes: SMART Criteria
Expected outcomes are specific, measurable, and time-bound statements detailing how the goal will be achieved. They can be developed independently or using resources like the Nursing Outcomes Classification (NOC), a standardized system aligning with NANDA-I diagnoses.[3]
Outcomes must be patient-centered, starting with “The patient will…” and addressing defining characteristics of the nursing diagnosis. SMART criteria ensures effective outcome statements:[4]
- Specific: Clearly defines what needs to be achieved.
- Measurable: Uses objective criteria for evaluation.
- Attainable/Action-Oriented: Patient-driven actions, using action verbs.
- Relevant/Realistic: Considers patient’s condition, values, and resources.
- Time-limited: Includes a timeframe for evaluation.
Figure 4.9
SMART Components of Outcome Statements
Example (Scenario C – Fluid Volume Excess): “The patient will have clear bilateral lung sounds within the next 24 hours.” (SMART: Specific – lung sounds, Measurable – clear, Action-oriented – have, Realistic – achievable in 24 hours, Time-limited – 24 hours).
Verbs for Measurable Outcomes:
Figure 4.10
Measurable Outcomes
Action Verbs for Outcome Statements:
Figure 4.11
Action Verbs
Step 4: Planning – Designing Nursing Interventions
Planning, the fourth step and ANA Standard, involves the “registered nurse [developing] a collaborative plan encompassing strategies to achieve expected outcomes.”[16] This means selecting evidence-based nursing interventions – actions nurses take to reach patient outcomes. Interventions should aim to address the related factors of the nursing diagnoses.[2] The Nursing Interventions Classification (NIC) system is a valuable resource for evidence-based interventions.[3]
Types of Nursing Interventions: Independent, Dependent, and Collaborative
Nursing interventions can be direct care (patient contact) or indirect care (support activities). They are also classified as independent, dependent, or collaborative.
Figure 4.12
Collaborative Nursing Interventions
Independent Nursing Interventions
Independent nursing interventions are actions nurses can initiate without a provider’s order. Examples include patient education, repositioning, and monitoring.
Example (Scenario C – Fluid Volume Excess): “The nurse will reposition the patient every 2 hours to promote comfort and skin integrity.” (Based on evidence for edema management[5]).
Dependent Nursing Interventions
Dependent nursing interventions require a provider’s prescription, such as medication administration.
Example (Scenario C – Fluid Volume Excess): “The nurse will administer furosemide 40mg IV daily as prescribed.”
Collaborative Nursing Interventions
Collaborative nursing interventions involve working with other healthcare team members like physicians, therapists, and social workers.
Example (Scenario C – Fluid Volume Excess): “The nurse will consult with respiratory therapy for oxygen management and breathing treatments as needed.”
Individualizing Interventions and Creating Care Plans
Interventions must be individualized to be effective. Patient preferences, cultural values, and available resources must be considered. Nursing care plans are the documented plan of care, legally required in many settings and essential for consistent, coordinated care. They can be standardized (with customizable options) or fully individualized.
Figure 4.13
Standardized Care Plan
Step 5: Implementation – Putting the Plan into Action
Implementation, the fifth step and ANA Standard, is when the “nurse implements the identified plan.”[18] This involves prioritizing interventions, ensuring patient safety, delegating appropriately, and documenting actions.
Prioritizing and Ensuring Patient Safety During Implementation
Prioritize interventions using Maslow’s Hierarchy and ABCs, similar to diagnosis prioritization. Patient safety is paramount. Continuously reassess patients before implementing interventions, and modify plans as needed. Nurses are crucial in preventing errors and improving healthcare quality.
Delegation of Nursing Interventions
RNs may delegate tasks to LPNs or UAPs, but remain accountable. Delegation must be appropriate based on patient condition, task complexity, and delegatee’s competence, following Nurse Practice Acts and agency policies. RNs cannot delegate tasks requiring clinical judgment.
Delegation Principles (Wisconsin Nurse Practice Act Example): RNs delegate tasks commensurate with competence, provide direction, monitor performance, and evaluate effectiveness. LPNs accept assignments they are competent in, provide basic care, report changes, and consult with RNs or providers when needed. [10, 11]
Documentation of Interventions
Timely documentation of implemented interventions is essential for communication and legal accountability. “If it isn’t documented, it wasn’t done.”
Coordination of Care and Health Teaching/Health Promotion
ANA standards also include Coordination of Care and Health Teaching and Health Promotion within Implementation.[12] These involve organizing care, engaging patients in self-care, advocating for holistic care, and providing patient education during every encounter.
Step 6: Evaluation – Assessing Outcome Achievement
Evaluation, the final step and ANA Standard, is when the “registered nurse evaluates progress toward attainment of goals and outcomes.”[21] This is an ongoing process, assessing both patient status and care plan effectiveness.[22]
Evaluation involves comparing reassessment data to expected outcomes to determine if they were met (met, partially met, or not met). If outcomes are not met, the care plan must be revised. Revision questions include: Were outcomes realistic? Are diagnoses accurate? Are interventions effective? What barriers exist?
Example (Scenario C – Evaluation):
Outcomes for Fluid Volume Excess were:
- Decreased dyspnea within 8 hours.
- Clear lung sounds within 24 hours.
- Decreased edema within 24 hours.
- Weight return to baseline by discharge.
Evaluation Day 1: “Patient reports decreased dyspnea, lung sounds clear, weight down 1 kg, 2+ edema persists.” Outcomes “Partially Met.” Care plan revised with TED hose and leg elevation interventions. Risk for Falls outcome “Met” – patient understands safety measures, no falls occurred.
Evaluation results are documented in the patient’s medical record.
Summary: The Dynamic Nursing Process
The nursing process, guided by critical thinking and clinical judgment, is a dynamic and patient-centered approach to care. Utilizing resources like NANDA nursing care plans and the NANDA nursing diagnosis list 2018 2020 provides a structured framework for effective and standardized nursing practice. Continuous reassessment and plan revision ensure optimal patient outcomes.
Video Review: Creating a Sample Care Plan
Learning Activities
[Interactive learning activities related to creating a nursing care plan – omitted for brevity as per instructions]
Glossary
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References
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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. ↵ [PubMed: 32569111]
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. ↵ [PubMed: 32569111]
3.Powers, L., Pagel, J., & Herron, E. (2020). Nurse preceptors and new graduate success. American Nurse Journal, 15(7), 37-39. ↵.
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5.Gordon, M. (2008). Assess notes: Nursing assessment and diagnostic reasoning. F.A. Davis Company. ↵.
6.NCSBN. (n.d.). NCSBN clinical judgment model. https://www.ncsbn.org/14798.htm↵.
7.American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
8.American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
9.“The Nursing Process” by Kim Ernstmeyer at Chippewa Valley Technical College is licensed under CC BY 4.0↵.
10.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↵.
11.Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York. ↵.
12.American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
13.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↵.
14.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. ↵.
15.Campbell, J. (2020). SMART criteria. Salem Press Encyclopedia. ↵.
16.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↵.
17.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.↵.
18.RegisteredNurseRN. (2015, June11). Nursing care plan tutorial | How to complete a care plan in nursing school. [Video]. YouTube. All rights reserved. Video used with permission. https//youtu.be/07Z4ywfmLg8↵.
19.Batalden P. B., Davidoff F. What is “quality improvement” and how can it transform healthcare?. BMJ Quality & Safety. 2007;16(1):2–3. ↵ [PMC free article: PMC2464920] [PubMed: 17301192] [CrossRef]
20.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↵.
21.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/↵ [PubMed: 25077248]
22.Institute of Medicine. (2007). Preventing medication errors. National Academies Press. 10.17226/11623. ↵ [CrossRef]
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.Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York. ↵.
29.Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York. ↵.
Alt text descriptions for images:
- Figure 4.1: Alt: Nurse in a detective hat examining medical charts, symbolizing inductive reasoning in nursing to find patient cues.
- Figure 4.2: Alt: “Quiet Zone” sign in a library, illustrating deductive reasoning by applying a general quiet policy to a specific hospital setting.
- Figure 4.3: Alt: Circular diagram titled “The Nursing Process” with arrows showing the cyclical flow through Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.
- Figure 4.4: Alt: Nurse holding elderly patient’s hand, demonstrating touch as therapeutic communication and caring in nursing.
- Figure 4.5: Alt: Nurse sitting on patient’s bed, engaging in conversation and building rapport to gather subjective assessment data.
- Figure 4.6: Alt: Nurse performing lung auscultation on a patient, illustrating objective data collection during a physical examination.
- Figure 4.7: Alt: Infographic titled “The How To of Prioritization” showing a step-by-step guide for nurses to prioritize patient care.
- Figure 4.8: Alt: Maslow’s Hierarchy of Needs pyramid, demonstrating the prioritization of physiological and safety needs in nursing.
- Figure 4.9: Alt: Diagram titled “SMART Components of Outcome Statements” outlining Specific, Measurable, Attainable, Relevant, and Time-bound criteria for nursing outcomes.
- Figure 4.10: Alt: Table listing measurable verbs like define, list, verbalize, and demonstrate, contrasting with non-measurable verbs for writing effective outcome statements.
- Figure 4.11: Alt: Table listing action verbs such as administer, assess, collaborate, and educate for use in writing action-oriented outcome statements in nursing.
- Figure 4.12: Alt: Multidisciplinary team of doctors and nurses discussing patient care, representing collaborative nursing interventions and planning.
- Figure 4.13: Alt: Example of a standardized nursing care plan document in an aged care home, illustrating a structured format for care planning.
- Video Image: Alt: Screenshot from a YouTube video titled “Nursing care plan tutorial” about creating a nursing care plan in nursing school.
