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Chapter 6
Nursing Process and Critical
Thinking
Jeanelle F. Jimenez RN, BSN, CCRN
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Introduction
• Nursing defined
• Nursing process


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Organizational framework for the practice of nursing
Problem solving
Six phases per the ANA or a modified 5 phases
(ADPIE)
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 2
Figure 6-1
(Modified from Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Relationships among the steps of the nursing process.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 3
Assessment
• AKA “Data Collection” for the LVN/LPN
• A systematic, dynamic process by which the nurse,
through interaction with the patient, significant other,
and health care providers, collects information and
analyzes data about the patient
• Subjective vs. Objective Data
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 4
Sources of Data
• Primary Source
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
Patient
Most accurate
• Secondary Sources
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Family members, significant other, medical records,
diagnostic procedures, and nursing literature
When the patient is unable to supply information,
secondary sources are used
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 5
Methods of Data Collection
• Interview

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Biographical data
Reason patient is seeking health care
History of present illness
Past health history
Environmental history
Psychosocial history
• Physical Exam

Head-to-toe format
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 6
Diagnosing
• American Nurses Association defines as “A clinical
judgment about the patient’s response to actual or
potential health conditions or needs. Diagnoses
provide the basis for determination of a plan of care
to achieve expected outcomes.”
• The RN is responsible for formulating a nursing
diagnosis.
• The LPN or RN may both observe and collect data.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 7
Diagnosing
• Nursing Diagnosis

North American Nursing Diagnosis Association
International (NANDA-I)
• The nursing diagnosis is an identification of a health
problem stated by utilization of the approved NANDA
format.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 8
Diagnosing
• Constructing a Nursing Diagnosis
• May be a 2-part or 3-part nursing diagnosis
1. Select a nursing diagnosis label from the NANDA list
2. List the contributing, etiologic, or related facts
3. The specific cues, sings, and symptoms from the
patient’s assessment
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 9
Planning
• The nurse establishes priorities of care, writes
desired patient outcomes, selects and converts
nursing interventions into nursing orders, and
communicates the plan of care.
• Nurse must decide what can be done to lessen or
solve an actual problem or prevent a risk problem
from becoming an actual problem.
• The nurse decides what interventions will be
effective.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 10
Planning
• Priority Setting
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Nursing diagnoses are ranked in order of importance
for the patient’s life and health.
Physiologic needs come before safety and security.
Safety and security needs come before love and
belonging needs.
Life-threatening and health-threatening problems are
ranked before other types of problems.
Actual problems may be ranked before risk problems.
Priorities change as the patient progresses in the
hospitalization; as some problems are resolved, new
ones can be addressed.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 11
Planning
• Establishing Desired Patient Outcomes
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The nurse predicts the condition of the patient
following nursing interventions.
This prediction is expressed in a statement that
indicates the degree of wellness desired, expected, or
possible for the patient to achieve.
Outcome: A statement provides a description of the
specific, measurable behavior that the patient will be
able to exhibit in a given time frame following the
intervention.
Goal: A statement about the purpose to which an
effort is directed.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 12
Planning
• A Well-Written Patient-Centered Goal/Desired
Outcome Statement Achieves the Following:
Uses the word “patient” as the subject of the
statement
 Uses a measurable verb
 Is specific for the patient and the patient’s problem
 Is realistic for the patient and the patient’s problem
 Includes a time frame for patient reevaluation

• Interventions may be done/developed by the nurse
or ordered by the physician
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 13
Implementation
• Phase of the nursing process in which the
established plan is put into action to promote
achievement of the outcome.
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This phase includes ongoing activities of data
collection, prioritization, performance of nursing
interventions, and documentation.
Both nurse- and physician-prescribed therapy are
included.
Documentation is a vital component of the
implementation phase.
“If it was not charted, it was not done” is a constant
principle of nursing.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 14
Evaluation
• A determination is made about the extent to which
the established outcomes have been achieved.

Review the patient-centered goals/desired patient
outcomes that were established in the planning
phase.
 Reassess the patient to gather data indicating the
patient’s actual response to the nursing intervention.
 Compare the actual outcome with the desired
outcome and make a critical judgment about whether
the patient-centered goals/desired patient outcome
was achieved.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 15
Evaluation
• The nurse should make one of three judgments or
decisions

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The outcome was achieved.
The outcome was not achieved.
The outcome was partially achieved.
• The plan of care is changed during this phase of the
nursing process.
• Modifications can be made if the outcome has been
achieved, partially achieved, or not achieved.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 16
NANDA, NIC, NOC
• The NANDA-I Has Formed a Relationship With Two
Other Groups.



Nursing Intervention Classification (NIC) is a research
group working at the University of Iowa to standardize
the language used to organize and describe
interventions.
Nursing Sensitive Outcome Classification (NOC) is a
research group working at the University of Iowa who
have developed a standardized system to name and
measure the results of patient outcomes.
NANDA-I, NIC, and NOC are working together to
standardize the language of nursing.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 17
Role of the Licensed
Practical/Vocational Nurse
• The nursing process may vary from state to state;
review the state’s nurse practice act.
• Provide direct bedside nursing care.
• This direct care position allows the LPN/LVN to
closely observe, prioritize, intervene, and evaluate
the care provided to and for the patient.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 18
Role of the Licensed
Practical/Vocational Nurse
• Role of the Licensed Practical/Vocational Nurse in
the Nursing Process

Assessment
• Observe and report significant cues to the charge nurse
or physician.

Diagnosis
• Assist with the determination of accurate nursing
diagnoses.
• Gather data to confirm or eliminate problems.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 19
Role of the Licensed
Practical/Vocational Nurse
• Role of the Licensed Practical/Vocational Nurse in
the Nursing Process

Planning
• Assist with setting priorities.
• Suggest interventions.
• Assist with the development of realistic patient-centered
desired patient outcomes.

Implementation
• Assist with the establishment of priorities.
• Carry out physician and nursing orders.
• Evaluate the effectiveness of nursing activities.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 20
Role of the Licensed
Practical/Vocational Nurse
• Role of the Licensed Practical/Vocational Nurse in
the Nursing Process

Evaluation
• Assist with reevaluation of the patient’s health state
after nursing interventions.
• Suggest alternative nursing interventions when
necessary.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 21
Nursing Diagnosis and Clinical
Pathways
• Managed Care

A health care system whose aim is to enhance
specific clinical and financial outcomes within a
specific time frame
• Case Management

A certified nursing specialty; refers to the assignment
of a health care provider to a patient so that the care
of that patient is overseen by one individual
 Assists the patient and family to receive required
services, coordinates these services, and evaluates
the adequacy of these services
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 22
Nursing Diagnosis and Clinical
Pathways
• Clinical Pathways
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Multidisciplinary plan that schedules clinical
intervention over an anticipated time frame for
high-risk, high-volume, high-cost types of cases
Includes such elements as diagnostic tests,
treatments, activities, medications, consultations,
education, daily outcomes, and discharge planning
• Variance

Patient does not achieve the projected outcome
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 23
Critical Thinking
• Critical thinkers think with a purpose.
• They question information, conclusions, and points
•
•
•
•
of view.
They are logical and fair in their thinking.
Critical thinking is a complex process, and no single
simple definition explains all of the aspects of critical
thinking.
The nurse must be able to not only perform skills but
also think about what he or she is doing.
Nurses use a knowledge base to make decisions,
generate new ideas, and solve problems.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 24
Critical Thinking
• Characteristics of Critical Thinkers
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Reflect or think about what is being learned.
Look for relationships between concepts or ideas.
Analyze or critique behaviors.
Make self-correction.
Realize they do not know everything.
Involve creative thinking.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 25
Critical Thinking
• Individuals Can Become Better Critical Thinkers

Verbalize thoughts aloud.
 Hear others think aloud to help learn how other
people reason.
 Study to gain specific theoretical knowledge; ask
other people to evaluate their thinking; and use
mistakes to learn.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 26
Evidence-Based Practice
• Research versus educational knowledge,
consultation with peers, and own experience
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 27
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