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Clinical judgment
The cognitive process of thinking about patient issues, making inferences, and deciding on the actions to be implemented in a particular situation.
Critical thinking
A complex phenomenon that involves an active, organized, cognitive process used to carefully examine one's thinking and the thinking of others.
Clinical decision-making
The use of critical thinking skills throughout the nursing process to obtain relevant information about the patient and to plan and provide effective care.
Nursing assessment
The collection of patient data from primary and secondary sources to inform diagnosis and interventions.
Cues
The patient's expressions and important information that the nurse obtains with their senses.
Inference
How the nurse interprets the cues and uses intuition and past experiences to help pick up on cues.
Nursing diagnosis
A clinical judgment about an individual, family, or community responses to actual and potential health problems or life processes that is within the domain of nursing.
Components of nursing diagnosis
Diagnostic label, descriptors, related factors, and defining characteristics.
Planning
Developing a plan for care that includes patient-centered goals, prioritization of needs/interventions, and collaboration with the patient, family, and interdisciplinary team.
Patient care plan
A written plan that includes assessment, nursing diagnosis, goals, interventions, and evaluation to organize information for sharing and communication between nurses.
Critical thinking
Critical reasoning, decision making, evidence-based practice, and the art of nursing that come together in the nursing journey.
Note
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