Nursing Process and
Critical Thinking
LEARNING OBJECTIVES
1. Define the term critical thinking.
2. Explain how critical thinking is used in each step of the
nursing process.
3. Define the term nursing process.
4. Describe how the nursing process relates to nursing.
5. Discuss the term assessment, and describe how it influ-
ences the nursing process.
6. List the components of the assessment step.
7. Describe the primary purpose of the analysis phase of
the nursing process.
8. Define outcome identification and planning, and give
an example of this step in the nursing process.
CHAPTER OUTLINE
Theoretical Concepts
Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Critical Thinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nurses Are Critical Thinkers . . . . . . . . . . . . . . . . . . . . . . . . . .
Nursing Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Evidence-Based Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NURSING PROCESS
Nursing process is a familiar term in nursing and is used as a way of
organizing nursing actions in healthcare delivery. It is a system-
atic, problem-solving approach to client care. It is considered a
critical thinking competency that assists the nurse to intervene
in client care. The nurse’s actions are based on reasoning and sci-
entific knowledge. By definition, the term process refers to a series
of actions that lead toward a particular result. When attached to
nursing, the term nursing process becomes a general description of
nursing: assessment, analysis/nursing diagnosis, planning, imple-
mentation, and evaluation. The nursing process is used to diag-
nose and treat human responses to health and illness (American
Nurses Association, 1980). The nursing process provides an or-
ganized structure and framework for the delivery of nursing care
in all settings. It provides the basis for critical thinking in nurs-
ing. Although the five steps can be described separately and in
22
9. Define what is meant by the implementation phase of the
nursing process.
10. Explain evaluation and include your understanding of
why it is an important step in the nursing process.
11. Define the term nursing diagnosis.
12. Differentiate nursing diagnosis from medical diagnosis.
13. Define NIC and NOC and their role in standardizing
nursing language.
14. Compare and contrast the two-part and three-part
Nursing Diagnosis Statement.
15. Define evidence-based nursing practice.
16. State two examples of nursing diagnoses.
Management Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Delegation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Communication Matrix . . . . . . . . . . . . . . . . . . . . . . . . .
Critical Thinking Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . .
Scenarios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NCLEX® Review Questions . . . . . . . . . . . . . . . . . . . . . . . . . . .
logical order, in practice the steps overlap and events may not
always occur in the order listed here. For purposes of understand-
ing this process, however, it is appropriate to work through each
phase in logical progression.
The five steps of the nursing process are presented, defined,
and illustrated to assist you in understanding the importance of
integrating this framework in your beginning mastery of nurs-
ing content. A model of each step will enable you to visualize
how the individual components can be translated into direct
nursing actions or behaviors.
Assessment
Assessment, the first step in the nursing process, refers to the
establishment of a database for a specific client. Assessment
requires skilled observation, reasoning, and a theoretical
 Nursing Process and Critical Thinking

Assessment Planning
Gather data Identify short- and long-term goals and outcomes
Objective data Prioritize nursing diagnoses
Subjective data Develop a plan based on goals and outcomes, including
Verify data a teaching plan
Confirm observations Anticipate needs of client and family based on
Organize data priorities
Make inferences from data Select nursing behaviors needed to accomplish goals
Communicate data Specify deadlines for completion of plan
Observe—Interview—Examine Coordinate care and community resources
Identify client needs Consider contingencies for modifying plan
Be aware of staff reactions to client Record relevant information
Assess sources of data
Client history
Data from family each individual client’s therapeutic plan of care, and once it is
Client status—physical/emotional established, the nurse is accountable for actions that occur
Signs and symptoms within the scope of this nursing diagnosis framework.
Test results and findings Nursing diagnosis is a clinical judgment about individual,
Recall stored knowledge family, or community responses to actual or potential health
problems/life processes. Nursing diagnoses provide the basis for
selection of nursing interventions to achieve outcomes for which
the nurse is accountable (North American Nursing Diagnosis
knowledge base to gather and differentiate, verify and organize Association, 1997). The nurse must use critical thinking and
data, and document the findings. The nurse gathers informa- decision-making skills when determining nursing diagnoses.
tion relevant to the client from a variety of sources and then
assigns meaning to this data. Assessment is a critical phase be- Outcome Identification and Planning
cause all the other steps in the process depend on the accuracy
and reliability of the assessment. Assessment is based on con- This phase refers to the identification of nursing actions that
cepts of physiology, pathophysiology, psychology, and social are strategies for achieving the goals or the desired outcome
adjustment. of nursing care. The planning and outcome phases are directly
Assessment is also the initial step in critical thinking that related to solving or alleviating the problems identified in the
leads to the appropriate nursing diagnosis. nursing diagnosis. The plan includes short- and long-term
client-centered goals, strategies for goal outcome, and nursing
Nursing Diagnosis measures for the delivery of care. During this phase, the nursing
diagnoses are prioritized to meet the client’s immediate needs.
Nursing diagnosis is an integral component of the nursing Clients should be involved in the planning phase to ensure
process. Following the assessment step of the nursing process, a that the client’s and the healthcare team members’ goals are
nursing diagnosis is formulated. Nursing diagnosis is the state- congruent. If they are not, goal achievement can be impaired.
ment of a client problem derived from the systematic collection Planning focuses on the development of a plan of care individ-
of data and its analysis. It is a clinical judgment about a desig- ualized for a specific client.
nated client, family, or community that provides the basis for Planning is based on the client’s healthcare needs, selected
completion of the nursing process. Nursing diagnosis includes goals, and strategies directed toward goal achievement. It is a
the etiology, when known, and relates directly to the defining plan of care in which the appropriate nursing actions and the
characteristics. Nursing diagnosis provides the foundation for client’s desires are considered and chosen to achieve a goal.

Implementation
Nursing Diagnosis The fourth phase in the nursing process is the implementation,
Analyze and synthesize collected data or intervention, phase. This phase refers to the priority nursing
Examine defining characteristics, both major and minor actions or interventions performed to accomplish a specified
Determine clusters of clues
goal. It explicitly describes the action component of the nurs-
ing process. This phase involves initiating and completing
Identify related factors
those nursing actions necessary to accomplish the identified
Identify potential nursing diagnoses
client goals and outcomes. Nursing actions must be appropri-
Develop nursing diagnosis appropriate to client ate, individualized for the client, and based on safe nursing
problem
practice; they should be formulated on scientific principles
and derived from the problem-solving process. Finally, the
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 Nursing Process and Critical Thinking
Implementation
Implement client care plan by giving direct care based
on goals and outcomes
Perform actions and procedures in accordance with
client needs
Counsel and teach client, family, or both
Use preventive, palliative, or emergency measures for
client’s welfare
Encourage independence and self-care
Motivate and maintain optimum wellness
Communicate appropriately to client and client’s
family
Record data
Continue assessment process
interventions must be congruent with the total medical as well
as nursing treatment plan. Implementation of the plan involves
giving direct care to the client to accomplish the specified goal.
Implementation is based on accurate and complete assessment,
interpretation of data, identified client needs, goals and outcomes,
analysis, nursing diagnosis, and strategies to achieve goals.
Evaluation
The final phase of the nursing process is evaluation. Evaluation
is the examination of the outcome of nursing actions or the ex-
tent to which the expected outcomes or goals were achieved.
Was the goal achieved? What parts of the goal were not
achieved? Was client behavior modified? Evaluation is a neces-
sary phase to complete the nursing process. It allows the nurse
to continue to identify goals in the overall treatment plan and
to alter the current plan to the client’s needs.
Evaluation is based on the previous phases of the nursing
process (assessment, analysis, outcomes and planning, and im-
plementation). The evaluation phase completes the process
and examines the outcome.
The nursing process has provided the framework for the
immense amount of nursing content that is contained in this
textbook. The rationale for choosing this framework is that it
provides a way to organize and present nursing knowledge as well
as being an essential component of providing quality client care.
Evaluation
Determine effects of nursing actions
Determine extent to which goals and outcomes were
achieved
Examine appropriateness of nursing actions
Investigate effect and degree of compliance for client
and family
Reassess care plan—judge if goal modification is
necessary
Consider alternative nursing actions
Record client responses
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CRITICAL THINKING
All nurses are required to use critical thinking skills as they
provide nursing care for clients. Nurses are expected not only
to master nursing content from many disciplines, but to think
creatively, solve problems, communicate, and use reflective
judgment in the practice of nursing. Though critical thinking
involves problem solving and decision making, it is a more
complex process involving higher-level thinking. It employs
interpretation, analysis, evaluation, and inference. Critical
thinking requires understanding abstract ideas, consideration
of the context in which a situation exists, and openness to
new ideas.
There is no single accepted definition, but many authors
have defined critical thinking in terms that are relevant to
nursing. The word critical is derived from the Greek word
kritikos, meaning “critic.” To be critical means to ask questions,
to analyze, to examine your own thinking and the thinking of
others (Chaffee, 1994). Critical thinking focuses on judgment,
and nurses must use reflective judgment because each clinical
situation they encounter is different and unique. Effective
critical thinking and problem solving actually depend on rele-
vant knowledge and previous experience (Facione 1998;
McKeachie, 1999). The definition of critical thinking by
Scriven and Paul (1996) for the National Council for
Excellence in Critical Thinking Instruction is widely accepted
today by many in the field of education. “Critical thinking is
an intellectually disciplined process of actively and skillfully
conceptualizing, applying, analyzing, synthesizing, and/or
evaluating information gathered from, or generated by obser-
vation, experience, reflection, reasoning, or communication,
as a guide to belief and action.” To expand on this statement,
critical thinking requires cognitive skills, the ability to ask
pertinent questions, knowledge, and the ability to think
clearly. As stated, an important aspect of critical thinking is
also the ability to use reflection and language properly.
Reflection is the action of thinking back or recalling an earlier
clinical situation, remembering nursing actions that worked or
didn’t work, and determining whether this information is help-
ful in the current situation. The ability to use language is asso-
ciated with the ability to think meaningfully. Thinking and
language are closely related processes (Miller & Babcock,
1996). To become a critical thinker, the nurse must use lan-
guage accurately. If nurses are unable to use appropriate termi-
nology, communication with the client and other healthcare
workers may be impaired. In addition to these skills, nurses
need to be creative thinkers in order to develop appropriate
plans of care for clients.
Critical thinking competencies are the cognitive processes
a nurse uses to make judgments. Specific critical thinking com-
petencies in clinical situations include diagnostic reasoning,
clinical inferences, and clinical decision making. These
competencies are used by many healthcare professionals. The
nursing process is considered the specific critical thinking com-
petency in nursing. Diagnostic reasoning is a series of clinical
judgments made during and after data collection, resulting in
an informal judgment or formal diagnosis (Carnevali &
Thomas, 1993). The clinical decision-making process uses
 Nursing Process and Critical Thinking
reasoning to ensure that after evaluating all options available,
the best are chosen to improve the client’s health status.
Critical thinking skills assist the nurse to look at all as-
pects of a situation and then arrive at a conclusion. Critical
thinkers identify and question assumptions, determine what is
important in each situation, and examine each alternative
before making an informed decision. When critical thinking
is employed in a clinical situation, you would expect that one
would examine ideas, beliefs, principles, assumptions, conclu-
sions, statements, and inferences before coming to a conclu-
sion and then making a decision. The conclusions and
decisions made by nurses affect clients’ lives; therefore, they
must be guided by precise, disciplined thinking, which leads
to accurate and complete data collection. While examining
the situation, using these concepts, the nurse would also be
using scientific reasoning, the nursing process, and decision-
making processes.
NURSES ARE CRITICAL THINKERS
Nurses are required to be problem solvers and decision makers,
to acquire nursing judgment skills, and to think critically in
order to practice in today’s nursing climate. Decision-making
and problem-solving skills are necessary for managing and
delivering client care. Both of these skills require critical
thinking.
Watson and Glaser have described critical thinking as a
process that defines a problem, selects pertinent information
for a solution, recognizes stated and unstated assumptions, for-
mulates and selects relevant hypotheses, draws conclusions,
and judges the validity of inferences. The outcome of critical
thinking is forming a conclusion and stating the justification
for that conclusion. This is what differentiates critical thinking
from usual thinking.
Nurses who are considered critical thinkers are those who
use logic, creativity, and good communication and are flexible
and competent in delivering client care. Additional attitudes
attributed to nurses who are considered critical thinkers include
open-mindedness, empathy, realism, and being a team player.
Nurses use critical thinking skills as they relate theory to
practice, apply the nursing process in client care, and make
critical clinical decisions. The ability to use critical thinking
skills assists the nurse to recognize and analyze problems and to
solve them using a systematic approach.
To acquire critical thinking skills, the nurse must first de-
velop a sound theoretical knowledge base. This means study-
ing the concepts appropriate to each clinical discipline (e.g.,
the pathophysiology related to the medical diagnosis or disease
state; knowledge of pharmacology, growth and development,
nutrition, and psychology; and client problem in each area of
nursing practice). This knowledge is transferred to clinical sit-
uations by determining the appropriate nursing diagnosis in
order to provide safe client care and make independent judg-
ments. In addition to reflecting on previous knowledge, the
nurse gains immeasurable experience in the identification of
clients’ problems with each clinical experience. Over time, the
nurse is able to select the best solution for assisting clients to
resume a healthy state.
Critical thinking is a process as well as a cognitive skill that
is used to identify and define problems, assess clients, and eval-
uate their responses to treatment and care. Nurses select and
classify data and organize it into clusters or patterns to formu-
late nursing diagnoses. Critical thinking is used when multiple
nursing actions are considered and the most appropriate action
is selected for each client problem. After the client interven-
tion is carried out, the effectiveness of the intervention and
client outcome is evaluated using critical thinking. It is easy to
see from this statement that critical thinking is used through-
out the steps of the nursing process.
You have used problem-solving methodologies throughout
your education as you have faced everyday situations. The nurs-
ing process provides the basis for critical thinking in nursing
when problem solving is required in client care. The following
examples demonstrate how critical thinking is used throughout
the five steps of the nursing process. When the steps are fol-
lowed consistently and accuracy of the data is maintained,
habits that promote critical thinking in nursing are developed.
Assessment in Critical Thinking
Identifying essential assessment data and where the data can
be found requires critical thinking. Obtaining, classifying, and
organizing data is a principal function of critical thinking.
A leading cause of error in making clinical judgments or de-
cisions is the collection of inaccurate or incomplete data during
the assessment phase. The data collection or assessment step of
the nursing process assists the nurse to predict, detect, prevent,
and control client problems. A nurse with good critical think-
ing skills develops a systematic approach to obtaining and vali-
dating data. This includes using all sources for data collection
(i.e., reviewing the client’s chart, asking pertinent questions,
and completing the assessment in a systematic manner). If an
assessment tool is used, ensure that thought goes into the way
the data is recorded; don’t just write information down in a rote
manner. Review the assessment form to determine whether ad-
ditional or more in-depth information is required based on the
initial findings—this action involves critical thinking. Ask
yourself, “Is this information relevant?” and “Do I need to assess
anything else?” Listen to the client. Clients provide important
subjective data to add to objective information. Once all of the
data are collected, information should be validated to ensure
that data are not missing and that existing data are correct.
Data also need to be organized or categorized in a usable system.
Clustering of similar information assists the nurse in forming a
picture of the client’s problems and strengths. Critical thinking
is necessary to determine the significance of reported data, and
clustering identifies whether patterns of behavior or responses
exist. Clustering data helps determine relevant from irrelevant
data as well as gaps in information. It also pinpoints cause-and-
effect relationships. Once the clustering is completed, infer-
ences may be formulated.
Nursing Diagnosis in Critical Thinking
A nursing diagnosis is the identification of a client problem.
Before a nursing diagnosis is made, the nurse has critically ana-
lyzed, synthesized, clustered, and interpreted all the collected
data. Use of critical thinking skills is essential in this step of
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 Nursing Process and Critical Thinking
the nursing process. As you cluster data, you are applying the
scientific principle of classifying information in order to deter-
mine whether relationships exist among the data and whether
data are relevant or irrelevant in this situation. As information
is clustered, inconsistencies among the collected data may
prompt the nurse to look for additional assessment findings.
Determining when additional information is needed for an
accurate diagnosis prevents the nurse from making a very com-
mon critical thinking error—making a judgment based on in-
complete information. It is important to recheck the client’s
records, asking additional questions of the client in order to
obtain the necessary information needed to complete the ap-
propriate nursing diagnosis. After the data are clustered, the
nurse begins to organize defining characteristics into meaning-
ful patterns. This is a major step toward identifying the client’s
problems. Usually, the presence of two to three defining char-
acteristics validates the nursing diagnosis. The identification of
this information assists the nurse in determining the appropri-
ate nursing diagnosis. Identifying patterns requires critical
thinking skills associated with a sound scientific knowledge
base. The nurse must differentiate the normal from the abnor-
mal findings, as well as the risk factors for abnormal patterns of
functioning. Using a nursing diagnosis reference book will assist
the nurse in clarifying data relevant to defining characteristics
or risk factors related to the client’s clinical manifestations.
During this step of the nursing process, actual client
problems are identified, potential problems are predicted, and
priorities are established. Establishing nursing diagnoses is an
important independent action of the nurse; however, medical
diagnoses must be considered as well. Nursing diagnoses can-
not be treated in isolation. Collaborative problem identifica-
tion and treatment with other healthcare workers form the
basis of client care and contribute to a holistic approach to
client care. Priorities of care are determined by the severity of
the client’s problems. These priorities are identified within the
planning and intervention steps of the nursing process.
Planning in Critical Thinking and
Outcome Identification
Long- and short-term goals are formulated after deliberating
with the client, family, and other healthcare team members.
Defining realistic goals that are acceptable to the client re-
quires critical thinking. A prioritized plan of care is developed
during this phase of the nursing process.
Determining outcomes (goals) and strategies for achieving
goals are paramount to providing effective client care. Out-
comes are time-specific as well as setting-specific. Long-term
outcomes or goals are usually based on what is expected by the
time of discharge from a nursing unit or a facility. In acute care
facilities, short-term outcomes are based on time frames as
short as by the end of the shift, within 24 hours, etc. The long-
term goal or discharge expected outcome should be determined
before other outcomes and interventions are initiated. When
setting priorities for client problems, keep in mind that treating
these problems must be addressed on the plan of care in order to
achieve the client’s discharge goal or outcome. There are two
critical thinking skills inherent in this step. One is listing the
26
client problems and determining whether there are relation-
ships between the problems, and the other is assigning the
problems by highest priority. These critical thinking skills
require sound scientific principles and scientific method, clini-
cal judgment, reasoning skills, and goal-directed thinking.
When listing the actual and potential problems identified
by the assessment data, identify which problems need immedi-
ate intervention and those that are underlying causes of the
problems. Those situations identified as causing the problem
must be assigned the highest priority. After listing the prob-
lems, determine whether there are relationships among
the problems. If relationships exist, explore how one problem
affects another. Maslow’s Hierarchy of Human Needs is employed
by many nurses to determine prioritization of problems. Maslow
lists problems with survival needs (food, fluids, oxygen) as the
highest priority. These needs must be addressed first in the plan of
care for the client’s well-being.
To write specific, realistic, client-centered outcomes, the
problems must be stated clearly. Outcomes are derived directly
from the problem statement, and the subject of the problem
statement is the client. An example of a clear, client-centered
outcome is “The client will ambulate the length of the hall be-
fore discharge.” Remember, problem statements are written as
nursing diagnoses. An example of a client outcome utilizing a
nursing diagnosis is “The client will demonstrate accurate ad-
ministration of insulin according to the guidelines established
by the diabetic educator within 24 hours of admission.” This
outcome is directly related to a “Knowledge Deficit: Insulin
Administration” nursing diagnosis. You will also notice there is
a time-specific statement included within the outcome state-
ment. This time frame assists the nurse to evaluate outcome
achievement and the need to re-evaluate the plan of care.
Implementation in Critical Thinking
Nursing interventions are specific strategies developed to achieve
positive client outcomes. These interventions are determined by
using the critical thinking skills of generalizing, explaining, and
predicting outcomes. After consideration of all identified possible
actions, nursing interventions are implemented.
Identifying appropriate nursing actions is critical to the out-
come of client care. Determining these actions requires critical
thinking skills. These skills include the ability to identify specific
actions, predict and monitor the client’s response to the actions,
and weigh risks and consequences of each action. Examining the
risks and consequences of an action, a nurse is determining the
most beneficial and least harmful approach to client care. When
interventions are clearly delineated on the plan of care, the like-
lihood of the actions being carried out is enhanced. The more
specific the intervention, the greater chance of outcome success.
If increasing fluid intake is the intervention, specifics regarding
fluid likes and dislikes of the client should be addressed. For
example, “Client prefers noncarbonated beverages at room
temperature.” Another example of a specific intervention is
“Ambulate the client after his bath, before lunch, and before
dinner.” This would be appropriate for the goal to ambulate the
length of the hall by discharge. Putting times for interventions
or distances for ambulation increases the likelihood of compli-
ance with the intervention by all healthcare workers.
 Nursing Process and Critical Thinking
Evaluation in Critical Thinking
During the final phase of the nursing process, the nurse criti-
cally analyzes each of the client outcomes. If the client need
(goal/objective) was not met, the plan is revised. Clearly docu-
menting a comprehensive plan provides the basis for evalua-
tion. Evaluating progress toward outcome achievement assists
the nurse in evaluating the effectiveness of the plan. A critical
thinking question during this phase of the nursing process is
“How well did the client accomplish the goal?” The nurse
might also ask “What could have been done differently?”
NURSING DIAGNOSIS
An important implication of nursing diagnosis is that it refers
to a health problem or condition that nurses are legally li-
censed to treat. Establishment and acceptance of using nursing
diagnoses will demonstrate recognition and legal sanction of
nursing as a profession with its own body of knowledge, educa-
tion, and experience.
Nursing diagnoses provide the basis for selection of nursing
interventions to achieve outcomes for which the nurse is ac-
countable. In 1987, the Center for Nursing Classification at the
University of Iowa College of Nursing introduced the Nursing
Interventions Classification (NIC) system and in 1991 the
Nursing Outcomes Classification (NOC) system. These classifi-
cation systems and NANDA were merged and formed the
NNN Alliance International in 2001. NIC is a comprehensive
list of nursing interventions that are grouped according to nurs-
ing activities. The NIC includes physiological and psychosocial
interventions to treat and prevent illness and promote health
for clients, families, and the community. NOC has developed a
taxonomy of standardized outcomes to measure the effects of
nursing interventions. These outcomes can be used in all set-
tings and with all client populations. Nursing diagnosis text-
books are now integrating the three components. Each nursing
diagnosis statement includes domains, classes, diagnosis, out-
comes, and interventions. The nursing diagnoses are continu-
ally changing as the NANDA research continues. New diag-
noses are introduced at each biennial meeting.
Nursing diagnosis will play a pivotal role when evidence-
based, professionally led nursing care is more universally im-
plemented in client care. Using standardized terminology, such
as Nursing Diagnosis, Nursing Interventions Classifications
(NIC), and Nursing Outcomes Classifications (NOC) as elec-
tronic client health records become a requirement, will allow
for systematic collection of nursing data across all healthcare
organizations. Collecting data in this manner provides for
analysis and audit of a large volume of information at minimal
cost. Standardized terminology more effectively meets client
needs while ensuring client safety.
The term nursing diagnosis is not comparable to or the same
as a medical diagnosis. The major difference between medical
and nursing diagnoses is the focus on illness, injury, or disease
by the physician. The nursing diagnosis focuses on the re-
sponse to actual or potential health problems or life processes
and the client’s responses to illness, change in lifestyle, etc.
Medical diagnoses do not vary until treatment is completed,
whereas the nursing diagnosis is fluid and changes as the
Comparison of Diagnoses
Medical Nursing
Cancer of liver Pain, acute
Heart failure Fluid volume, excess
Chronic obstructive Breathing patterns,
pulmonary disease ineffective
client’s condition or response to treatment changes. Nursing
diagnosis highlights critical thinking and decision making and
provides a universal terminology that all nurses, irrespective of
work site, can understand. Nursing diagnosis is derived from
the assessment phase of the nursing process and is based on
both subjective and objective data. As the database evolves,
patterns of health problems emerge, and alterations from nor-
mal health states are identified. A nursing diagnosis is a con-
cise label that describes the observed behavior of the client.
The nursing diagnosis can be an actual or potential problem.
The specific problem identified implies that the nurse is quali-
fied and prepared to intervene and treat that condition. The
nurse is not legally able to intervene and treat a medical diag-
nosis without specific physician’s orders. Thus the nurse is not
able to intervene if the client has a diagnosis of, for example,
potential atelectasis or pneumonia. This is a medical diagnosis,
whereas breathing pattern, ineffective, is a nursing diagnosis, and
nursing interventions can be instituted to assist the client.
Nursing diagnoses provide a written communication to all
healthcare workers regarding the client’s status. The use of
nursing diagnoses provides a vocabulary that is used to describe
specific nursing practice, research, and education. It provides a
method to synthesize and communicate nurses’ observations
and judgments to all members of the healthcare team.
Types of Nursing Diagnoses
The North American Nursing Diagnosis Association
(NANDA International) states that a nursing diagnosis can be
written as an “actual” or as a “risk for” statement, “possible,”
“syndrome,” or “wellness.”
Actual: The nurse has validated an actual nursing diagnosis
using clinical judgment, and the client has presented with spe-
cific defining characteristics.
Risk for: Based on clinical judgment, the client is more vulner-
able to develop the problem than others in similar circum-
stances. This may also be referred to as a “potential problem.”
Risk diagnoses include risk factors.
The term possible diagnosis is not considered a type of diag-
nosis. It is an option indicating some data are present to con-
firm the diagnosis, but the data are incomplete or insufficient.
Writing a nursing diagnosis as “possible” alerts other nurses of
your concern but there is insufficient data to support a specific
diagnosis as yet. Further data collection is needed to confirm or
deny the diagnosis.
The term syndrome is used when a cluster of specific nursing
diagnoses is seen together. A wellness diagnosis describes a
client at a low level of wellness. Many diagnoses are further
27
 Nursing Process and Critical Thinking

qualified by terms such as effective, ineffective, impaired, im-
balanced, readiness for, disturbed, and decreased.
Diagnostic Statement
The diagnostic statement describes the health status of the client
and the factors that have contributed to the status. These state-
ments have been developed through research by NANDA and
are termed nursing diagnoses. One hundred eighty-eight nursing
diagnoses were endorsed by NANDA International. For 2009 to
2011, there were 21 new diagnoses, 9 revisions, and 6 retired
diagnoses, for a total of 203 nursing diagnoses. Because of the
increased use of computers for documentation, a standardized
language for describing client problems is mandatory. Nursing
diagnosis provides the necessary terminology for use in a variety
of clinical settings. NIC can be used both with a paper-based doc-
umentation system and electronic documentation system.

TABLE 1 Nursing Diagnosis: Impaired Skin Integrity

Definition: Altered epidermis and dermis

Objective Defining Characteristics Subjective

Disruption of skin surface (epidermis) None identified
Destruction of skin layers (dermis)
Invasion of body structures

Related Factors/Risk Factors

External (Environmental) Internal (Somatic) Developmental

Chemical substances Alterations in turgor Extremes in age

Excretions and secretions Altered fluid status
Humidity Altered metabolic state
Hypothermia Altered nutritional state
Mechanical factors Altered pigmentation
Medications Altered sensation
Immobilization Immunological deficit
Extremes in age Skeletal prominence
Radiation

Suggestions for Use Suggested Alternative Diagnosis

Surgical Incisions Infection, risk for
Pressure Ulcers Tissue integrity, impaired
Abrasions Skin integrity, risk for impaired
NOC Outcomes Goals NIC Interventions
Wound healing as evidenced by Measurable or observable Cleanse, monitor, and promote
resolution of surrounding skin, progress toward optimal health healing of wound that is closed
erythema and skin approximation by staples

Nursing Actions

Assessment Client Teaching Collaborative Activities

Assess incision site for erythema,
edema, signs, and symptoms of
dehiscence or evisceration
Assess wound for signs and
symptoms of infection
Instruct client/family about signs Consult with dietician regarding
and symptoms of wound infection foods high in protein, vitamins,
minerals
Instruct client/family about care Consult with wound care
of incision and dressing change specialist

Source: NANDA International. (2008, November 10). Nursing Diagnoses; Definitions and Classifications, 2009-2011, 2nd ed. Oxford, United Kingdom:Wiley Blackwell.
28
 Nursing Process and Critical Thinking

TABLE 2 Nursing Diagnosis Care Plan Data

Each nursing diagnosis care plan includes the following data:
• Definition of the individual nursing diagnosis
• Defining characteristics as cues describing client behavior
a. Objective data, observed or gathered through other sources such as assessment findings by the nurse
b. Subjective data, verbalized by the client
c. Meaningful patterns that identify potential client problems
d. Two to three defining characteristics that verify an actual or potential nursing diagnosis
• Related factors or risk factors
a. “Related to” indicates what should change for the client to return to optimal health
b. Related factors are stated as: “related to,” “associated with,” or “contributing to” the diagnosis. They are classified as:
1. Environmental (external) (e.g., hypothermia, moisture, physical immobilization)
2. Somatic (internal) (e.g., alterations in fluid status, altered circulation)
3. Developmental factors (e.g., extremes in age)
c. Risk factors lead to potential nursing diagnoses
• Suggestions for use: how to use the diagnosis appropriately or differentiating it from similar diagnosis
• Suggested alternative diagnosis
a. Similar diagnosis that can be considered when identifying client’s problems
b. Diagnosis that can be substituted for one that only partially matches client data
• NOC outcomes
a. Client outcomes that reflect client states or behaviors that nursing care can affect
b. Outcomes are not goals but can be used to set goals
• Goals and evaluation criteria
a. Goals represent measurable or observable criteria that represent whether the client problems have been resolved
b. Use NOC outcomes, indicators, and measuring scales to establish goals
c. Documented times and dates for meeting goals are stated
d. Documentation of progress toward meeting goals is set according to client’s condition and standards set by facility
for documentation
• NIC Interventions
a. Guide for selecting appropriate interventions
b. Each intervention has a label name and a set of activities that are identified as steps to carry out the intervention
• Nursing activities are actions taken by the nurse related to the nursing diagnosis
a. Assessments
b. Nursing interventions
c. Client/family teaching
d. Collaborative activities with other healthcare team members

By 2010, the plan is that all healthcare events will be elec- Self-perception
tronically recorded, and healthcare agencies will be required to Role relationship
submit the data to regional and national data banks according Sexuality
to the Department of Health and Human Services (DHHS).
Coping/stress tolerance
With the implementation of the electronic health records
Life principles
(EHRs), standardized nursing languages such as NANDA
International (NANDA-I) will be used to provide a broad base Safety/protection
of nursing knowledge at the point of care. Comfort
The 2009–2011 Taxonomy of Nursing Diagnosis, now Growth/development
Taxonomy II, is a classification in which the diagnostic data
are grouped within the following concepts: Components of Nursing Diagnosis
Health promotion There are basically two formats used to write the nursing diag-
nosis: the two-part statement and the three-part statement.
Nutrition
The two-part statement is the most common type of format
Elimination and exchange used in practice. The first component is the Diagnostic Label
Activity/rest or problem statement. This describes the client’s response
Perception/cognition to an actual or risk health problem. The second component,
29
 Nursing Process and Critical Thinking

both. The etiology is combined with the problem statement by

An Actual Nursing Diagnosis, written as a three-part using the words “related to,” for example, prolonged bed rest.
statement: S signifies the relevant signs and symptoms—usually a sum-
DIAGNOSTIC LABEL Transfer ability, mary of the objective assessment findings (signs) and subjec-
(Problem) impaired tive data reported by the client (symptoms). The phrase that
CONTRIBUTING FACTORS Related to inability to move connects this part of the statement is “as evidenced by”; for ex-
(Etiology or Cause) left side
ample, Impaired Skin Integrity, related to prolonged bed rest,
CLINICAL Evidenced by flaccid
as evidenced by a 2 * 2 cm circular red lesion or erythematous
MANIFESTATIONS paralysis of left side
(Defining Characteristics) macules with moderate serosanguineous drainage.
Although there are several approaches to formulating a
A Risk for Diagnosis, written as a two-part statement, statement of nursing diagnosis, the PES system is used by many
when there are no defining characteristics: schools of nursing throughout the United States.
DIAGNOSTIC Label Walking, impaired
(Problem)
RISK FACTORS Related to long leg cast EVIDENCE-BASED PRACTICE
secondary to fractured This term and use of evidence-based practice (EBP) is relatively
femur new to the practice of nursing, even though nursing has recog-
nized the importance of research as an essential basis for its devel-
opment. Nurses should make clinical decisions using the best
Etiology, is the cause or contributing factor to the problem. The available research and other evidence that is reflected in approved
two components are linked by the “related to (r/t)” term. policies, procedures, and clinical guidelines in a particular health-
The three-part statement includes the Diagnostic Label, care agency. Using evidence-based data is critical in nursing to
Etiology, and the Defining Characteristics. Defining Characteristics promote a consistent approach to client care that results in less
are defined as signs and symptoms or clinical manifestations and care-quality variability. This is significant as nurses provide care in
subjective and objective data. The characteristics are linked to settings where a group of nurses provides the care to groups of
the other two components by the “as evidenced by” statement. clients. Other health-related disciplines have long relied on this
The accompanying box is an example of nursing diagnoses type of empirical data when making clinical decisions.
written in a two-part and three-part statement. Evidence-based nursing practice is defined as the applica-
The PES framework is a commonly used approach or orga- tion of the best available empirical evidence that applies re-
nizing framework developed by Marjory Gordon that uses the cent research findings to clinical practice in order to aid clini-
three-part diagnostic statement. cal decision making.
P refers to the problem, or state of health, of the individual, Evidence-based nursing practice (EBNP) or evidence-based
family, or community. This problem is expressed as clearly as practice (EBP) is differentiated from research in several key ways.
possible; for example, Skin Integrity, Impaired. Basing nursing practice on evidence entails locating the latest re-
E describes the etiology, or probable cause, of the health search and other evidence, such as synthesizing results, and trans-
problem. This may refer to many factors that include client be- lating the evidence into a protocol or guideline that can be used
haviors, environmental components, or the interaction of to guide practice. Research is systematic investigation aimed at

Evidence-Based Research Project

When completing an evidence-based research project Step 4: Based on research findings, conduct a pilot study
you need to complete the following steps: to validate your hypothesis. Individuals can make
changes in a pilot study, but for an institution to make
Step 1: State the question you wish to study. It may be a
changes, a plan must be developed, it must be based on
simple question related to a standard nursing procedure
research findings, and it must be formally implemented.
that has been done a certain way for many years, or it
may be a totally new way of completing a procedure. Step 5: Obtain feedback from individuals involved in the
research. Monitor the research and identify the specific
Step 2: Gather the evidence (information). Do a literature
response(s) and alterations that have occurred in the
search, use the Internet, and review medical and nursing
practice setting as a result of the research findings.
studies reported in journals that relate to your subject of
interest. Step 6: Analyze and report the outcome resulting from
the research project. Reporting a change in practice that
Step 3: Analyze and assess the evidence. Did it come
improves nursing procedures will encourage others to
from a valid source? Who did the study, and how was the
make changes in practice settings as well.
study actually conducted?

Source: Domrose, C. (2001, November 19). Information based on interviews with nurse researchers and clinicians including Lisa Sams, Carolyn K. Davis, Kathleen Stevens,
Brigitte Failner. NurseWeek.

30
 Nursing Process and Critical Thinking
generating new knowledge or refining existing knowledge. EBNP
and research involve some of the same tasks, but the purposes of
the tasks differ in the way they achieve their goals. Research gen-
erates new knowledge, whereas EBNP applies the knowledge to
practice.
The levels of evidence vary among researchers. Some re-
searchers believe that the synthesis and use of scientific infor-
mation comes from randomized clinical trials. Others look at
the process more broadly and include information gleaned from
case reports and expert opinion to guide healthcare decisions.
The University of Minnesota Evidence-Based Health Care
Project concludes that evidence-based practice solves prob-
lems by carrying out four steps:
1. Identify issues or problems based on analysis of current
nursing knowledge and practice.
2. Identify relevant research through literature search.
3. Evaluate research by using criteria that has scientific merit.
4. Select interventions by using the most valid evidence.
Nurses must recognize the importance of using research
findings in clinical practice. It is paramount that nurses begin
to not just read research articles but critically examine the
content of the article and question current practice. Once re-
search data are available, nursing must consider making
changes in clinical practice based on the findings. In many fa-
cilities, this involves research teams that review current litera-
ture and then make appropriate recommendations for clinical
practice. Unfortunately, very little is known about the best
methods for implementing research evidence into nursing
MANAGEMENT Guidelines
Each state legislates a Nurse Practice Act for RNs, LVN/LPNs,
and advanced nurse practitioners. Healthcare facilities are
responsible for establishing and implementing policies and
procedures that conform to their state’s regulations. Verify the
regulations and role parameters for each healthcare worker in
your facility.
Delegation
• The RN’s responsibility when delegating client care tasks is
to ensure that the care plan is followed for each client.
Information contained on the care plan is reported to each
healthcare worker assigned to client care.
• The RN is responsible for implementing the nursing
process in all aspects of client care. LVN/LPNs may be as-
signed to carry out tasks within the nursing process, such as
assessing clients after the initial assessment and executing
interventions based on the client care plan. The RN, how-
ever, is ultimately responsible for client care, developing
the plan of care, and ensuring that the plan is followed.
• The LVN/LPN may assist the RN in planning and updating
the plan of care, but may not be responsible for this action.
• Assistive personnel, such as unlicensed assistive personnel
(UAP) and CNAs, are delegated client tasks, but do
practice. Evidence-based nursing will strengthen client out-
comes, improve client safety, provide effective nursing prac-
tice, and increase nursing’s credibility among other healthcare
professionals and the general public. This should be considered
another step in developing nursing’s theory base.
One note of caution when you are reading about evidence-
based practice: Do not confuse it with best practices. These
terms are sometimes used interchangeably, but they do not
mean the same thing. Best practices is a term used to describe
nursing interventions that have proven effective in promoting
positive client outcomes or in reducing overall costs to the
client or facility. Best practices refers to nursing practices that
are based on the “best evidence” available from nursing re-
search. The goal of best practices is to apply the most recent,
relevant, and helpful nursing interventions, based on research,
in real-life practice. Although the two terms, best practices
and EBP, are used interchangeably, the two are different in
some respects. Best practice is a generic or general phrase for a
process of infusing nursing practice with research-based knowl-
edge. EBP emerges from evidence-based medicine (EBM).
EBM is more rigorous and integrates individual clinical exper-
tise with evidence from systematic research. Systematic reviews
are more comprehensive in scope and quality of research, and
they use mostly randomized clinical trials as the gold standard
by which evidence is judged.
EBP will provide you with a framework for determining the
effectiveness of selected nursing skills and practice issues. As
you proceed through your nursing program, you will be ex-
posed to additional EBP research and its effect on clinical prac-
tice.
participate in the actual development of the plan of care.
Their input is valuable and should be considered when
changes in the plan of care are necessary.
• Critical thinking processes are used by all team members as
they provide client care. The RN has a more expanded sci-
entific knowledge base and experience in utilizing these
skills to provide the leadership necessary for effective and
safe client care. The RN must use these skills when assign-
ing client care and delegating activities.
Communication Matrix
• The RN synthesizes client data and determines the most
appropriate healthcare worker to provide care to each
client in her/his assignment.
• Each healthcare worker is given a report on activities to be
completed during the shift.
• Dissemination of client care information is based on the
client’s plan of care.
• Directions are given to all healthcare workers indicating
the type of client information the nurse needs immediately
and information that can be given during report times. For
example, if a client has a fever, the RN may want to know
the temperature as soon as it is obtained.
31
 Nursing Process and Critical Thinking
CRITICAL THINKING Strategies
Scenario 1
You have been assigned to care for Mr. Peters, a 76-year-old wid-
ower who was admitted with the diagnosis of heart failure. He
has lived alone for the last 2 years since his wife died. His chil-
dren live about 1 hour away and visit him once a month. The
children ordered Meals on Wheels for him, but he refused to eat
the food that was delivered. “I can do my own cooking, I am not
an invalid,” was the answer when the nurse asked why he didn’t
like the Meals on Wheels program. He had not seen the physi-
cian for at least 6 months. At the last visit, the physician pre-
scribed a moderately low-sodium diet, Lasix 40 mg daily, Calan,
and multiple vitamins. His admitting vital signs were BP 180/90,
P 98, R 22. His weight indicated a gain of 10 pounds since the
last visit. His physical assessment indicated rales in the lung
bases, 3+ edema of the ankles, and difficulty breathing in the
supine position, and with the least amount of exertion.
• How will you use the nursing process to determine an
accurate assessment database?
• What information is missing that might be important to
the nurse to assist in planning care for this client? What is
the best approach for obtaining the information?
• Identify at least four nursing diagnoses that are relevant for
this client’s plan of care. Write a two-part and a three-part
diagnostic statement for each nursing diagnosis.
NCLEX® Review Questions
Unless otherwise specified, choose only one (1) answer.
1. Place the steps of the nursing process in sequence.
1. Evaluation
2. Planning
3. Implementation
4. Assessment
5. Nursing diagnosis
2. Nurses who are considered critical thinkers exhibit which
of the following attributes?
Select all that apply.
1. Possess good communication skills and are flexible.
2. Use logic and creativity.
3. Are structured in their delivery of nursing care.
4. Use a systematic method for providing care in the
same order for each client.
3. Which one of the following examples accurately de-
scribes a properly stated nursing diagnosis?
1. Poor airway exchange r/t mucus accumulation in the
alveoli.
2. Client exhibits pain as a result of coughing as
evidenced by grimacing.
32
• Using a nursing diagnosis book, identify NIC and NOC state-
ments for the four nursing diagnoses listed in question 3.
• Identify the priority nursing diagnosis, and provide the
rationale for your decision.
• Develop a very brief nursing care plan using the nursing
process format as outlined in the text.
Scenario 2
8 AM. You are assigned to a 22-year-old male client who was
in a motorcycle accident yesterday. He sustained a compound
fracture of the right fibula and tibia. He states his pain is 9/10
and it is throbbing. He is nauseated all the time. He is sched-
uled for surgery later in the day. You assess his wound area and
notice there is a large amount of serosanguineous drainage in
the dressing. You reinforce the dressing.
• Based on the information provided in the scenario, identify
two nursing interventions.
• Determine priority nursing diagnoses and provide rationale
for your decision.
• Using a nursing diagnosis textbook, develop a client care
plan incorporating NIC and NOC data.
3. Knowledge deficit r/t inadequate understanding of
diabetes as evidenced by lack of regular blood glucose
testing.
4. Pneumonia r/t inadequate ventilation during
surgery.
4. Select all of the following diagnoses that are considered a
nursing, not a medical diagnosis.
1. Acute pain
2. Heart failure
3. Cancer of the liver
4. Ineffective breathing patterns
5. Pulmonary edema
6. Excess fluid volume
5. Evidence-based nursing practice research is used to
1. Aid in clinical decision making.
2. Determine the most often used method to provide
nursing care.
3. Develop new techniques for providing
nursing care.
4. Differentiate nursing diagnosis from medical
diagnosis.
 Nursing Process and Critical Thinking
6. The major role of assessment, the first step of the nursing
process, is to
1. Develop a nursing diagnosis after collecting client
health data.
2. Assess client and establish a database.
3. Identify short- and long-term goals based on client’s
verbal statements regarding health needs.
4. Assess sources of client data to determine whether ac-
curate and before implementing client care.
7. Client care planning effectively promotes compliance by:
1. Ensuring all healthcare needs are identified.
2. Developing the plan within 1 hour of admission.
10. Delegation of responsibilities to other healthcare members
3. Involving the client and family with the healthcare
team to develop congruent healthcare goals.
4. Including a teaching plan as part of the overall short-
term goals.
8. During the implementation phase of the nursing process,
the nurse
1. Gathers all data and prioritizes client needs.
2. Determines clusters of clues from collected data.
NCLEX-RN® Answers with Rationale
1. (4 5 2 3 1) When planning care, the steps in the nursing process are
completed in this order.
2. (1) and (2) Nursing care is provided to clients based on their individual
care needs. Critical thinking is implemented after collecting data and
then determining the needs of the client by priority. In addition to the
identified attributes, critical thinkers are realistic, good team players,
empathetic, and open-minded. Care is not delivered in the same way for
all clients.
3. (3) If you missed the question, it is suggested that you review nursing di-
agnosis statements. (4) is a medical diagnosis and (1) and (2) are written
incorrectly.
4. (1 4 6) These choices represent nursing diagnoses, whereas the other
diagnoses are medical. Nursing diagnoses can be treated by a nurse.
Medical diagnoses are treated by a physician, or the nurse can collabo-
rate on the treatment. Medical diagnoses require a physician’s order be-
fore the nurse can provide specific care to the client.
5. (1) Nurses should make clinical decisions using the best available re-
search and other evidence that is consistent with policies, procedures,
and clinical guidelines. (2) Best practices usually are indicative of the
most often used methods of providing client care. They are not necessar-
ily based on research findings. (3) and (4) do not describe, nor are they
involved in, Evidence Based Nursing. New techniques may come from
EBN but would be an off-shoot of the research, rather than the goal.
6. (2) After a complete assessment of the client, a data base of information
is then utilized to develop a nursing diagnosis, short- and long-term
3. Collects data and then provides education to client
and/or family.
4. Considers contingencies for modifying care plan.
9. The implementation of Nursing Interventions Classification
(NIC) with nursing diagnosis is primarily because
1. The diagnosis is stated more clearly in nursing termi-
nology.
2. It is not easily confused with a medical diagnosis.
3. It can only be used as a paper-based documentation
system.
4. It can be sent to national and regional databases.
can be completed in which one of the following situations?
1. Ask the unlicensed assistive personnel to assist in the
development of the client’s plan of care.
2. Assign the certified nursing assistants to clients who
require completion of care plan goals before discharge.
3. Ask the LVN (LPN) to assist in revising the care plan.
4. Request that the LVN (LPN) complete the initial care
plan after admitting the client.
goals, and appropriate interventions. (1), (3), and (4) actions will take
place after the assessment is completed.
7. (3) Compliance to client care goals is effectively carried out when the
client, family, and other individuals who will be participating in the care
take an active role. (4) Teaching plans are best developed using the
same group of individuals. (2) The care plan is developed as soon as pos-
sible after admission; follow hospital policy and procedure on time frame
for completion.
8. (3) The nurse would collect additional data if needed, then make the in-
tervention. Gathering data and prioritizing clients’ needs (1) are part of
the assessment phase of the nursing process. (2) is an action associated
with nursing diagnosis phase, and (4) is the last step of the nursing
process.
9. (4) The major advantage of using the NIC system is that it can be elec-
tronically sent to data bases. With the implementation of the electronic
health record, standardized nursing languages such as NANDA can be
used to provide a broad base of nursing knowledge at the point of care.
(3) NIC information can also be used as a paper-based document.
10. (3) LVN/LPNs can assist the RN in revising client care plans. These
health care workers (1) and (2) cannot complete the tasks identified in
the question. UAPs cannot develop a care plan, and CNAs are not al-
lowed to complete tasks prior to discharge, unless it is in their scope of
providing hygienic care, moving and positioning, etc. (4) Only RNs can
develop the plan of care at admission.
33
34
 Managing Client Care:
Documentation and Delegation

From Chapter 3 of Clinical Nursing Skills: Basic to Advanced Skills, 8/e. Sandra F. Smith. Donna J. Duelle. Barbara C. Martin. Copyright © 2012 by
Pearson Education. All rights reserved. 35