Nursing Process and Clinical Judgment — Key Terms for Exam
Nursing Resources and Tools
Two primary resources for nursing diagnoses (NANDAs) and clinical planning discussed in class:
NANDA-I nursing diagnosis taxonomy (the NANDA list) for standard problem labels and definitions.
StatRef (Stat Ref) digital library with a nursing pocket guide and access to NANDAs, drug guides, and other references.
Practical use of resources in this course:
Use StatRef to look up NANDAs and their defining characteristics and interventions.
Use the pocket guide (within StatRef) and the two core books shown in class for diagnosis prioritization and planning:
A visual, system-based approach to diagnoses (clinical usefulness, though not always containing every standard nursing diagnosis).
The Davis’ Drug Guide and Nurse's Pocket Guide to Diagnosis Prioritization (the latter is highlighted as particularly useful in class).
Platform access and setup:
Cape Fear Community College provides access; log in via the library quick links to reach StatRef.
Sign up for mobile access via the “login anywhere” option for clinical use.
Important concepts:
Nursing diagnoses are distinct from medical diagnoses and define the nursing scope of practice; they guide independent nursing interventions and care planning.
NANDAs provide a common language across settings; they underpin communication and documentation in Epic and other electronic systems.
While some institutions are transitioning to other terminologies, NANDAs remain a core tool in this course and practice setting.
The Nursing Process: Overview
The nursing process is the foundation of clinical thinking and patient care: a systematic, rational method of planning, delivering, and evaluating individualized nursing care.
Core sequence:
Assess
Diagnose (formulate nursing diagnoses)
Plan
Implement
Evaluate
Why it matters:
It structures thinking, improves patient safety, and helps with continuity of care across shifts and settings.
It supports safe care and clinical judgment, reducing the risk of errors and improving outcomes.
Important context:
Historical data show gaps in transition from education to practice; the nursing process helps reduce new-graduate errors by focusing on clinical judgment and systematic reasoning.
The process integrates evidence-based practice, critical thinking, and patient-centered goals.
Key associated concepts:
Clinical judgment model (Tanner): Noticing → Interpreting → Responding → Reflecting (evaluation).
Clinical judgment is the outcome of critical thinking applied at the bedside; critical thinking is developed in the classroom and foundational to clinical judgment.
The National Council of State Boards of Nursing (NCSBN) emphasizes clinical judgment as essential for safe practice.
Assessment: Data Types, Interviewing, and Data Sources
Two main data types:
Subjective data: what the patient or caregiver reports (e.g., pain level, dyspnea, nausea).
Objective data: what you observe or measure (e.g., vital signs, lung sounds, imaging results).
Data sources and methods:
Patient interview and health history
Physical examination and head-to-toe assessment
Medical records (Epic, EMR), prior notes, lab results
Reports from family or other health professionals
Interviewing skills (practical tips):
Start with courtesy: introduce yourself, explain your role, and ask permission to interview.
Build connection: sit at eye level, maintain eye contact, avoid talking to the computer screen only.
Use open-ended questions to elicit stories (What brings you in? How did you start feeling this way?) and reserve close-ended questions for specifics.
Avoid leading questions; use back-channeling (uh-huh, go on) and probing for depth when needed.
Manage privacy: confirm who is in the room and whether it’s okay to discuss sensitive topics; close curtains/doors as needed.
Manage interruptions and fatigue: plan 10–15 minute intervals, offer to resume later, and document after conversation.
Interview structure and tones:
Connection: introduce, state purpose, and establish rapport.
Comfort: minimize discomfort, ask about pain before starting, and ensure a comfortable environment.
Completeness: use open-ended prompts to gather a full story, then close with a summary and any follow-up questions.
Data collection and documentation:
Collect data using all senses; validate data when possible (e.g., re-check vitals with a different technique or instrument).
Distinguish between subjective and objective data, and document both with clear sources (patient quotes for subjective; measurement values for objective).
Interview content areas:
Cultural considerations, biographical information, chief complaint, present illness, past health history, family history, psychosocial history, spiritual health, review of systems.
Home environment, discharge planning expectations, and social support networks.
Cue Clustering and Data Organization
Cue: any data point gathered during assessment (subjective or objective).
Clustering cues: grouping related cues to determine patterns that indicate a nursing diagnosis or problem.
Purpose: to identify patterns that point to actual problems or risks, guiding the choice of diagnoses and interventions.
Tools used in class:
Concept maps to organize cues and relationships visually.
Gordon’s Functional Health Patterns as one method to organize cues (some students prefer concept maps; there’s flexibility).
Important practice: always document cues and the rationale for how they support inferences; you can branch to new questions but note where you’ll return to complete assessment data.
Critical Thinking, Clinical Judgment, and the Tanner Model
Definitions:
Critical thinking: intentional higher-level thinking; understanding content deeply and applying knowledge to generate and evaluate approaches for client care.
Clinical judgment (NCSBN perspective): the outcome of critical thinking applied in clinical practice; decision-making at the bedside.
Clinical judgment model (Tanner): Noticing → Interpreting → Responding → Reflecting/Evaluation.
How the model maps to practice:
Noticing: identify relevant data and cues from assessment.
Interpreting: derive meaning from data; interpret data in light of pathophysiology and nursing knowledge.
Responding: decide how to act; implement timely interventions to prevent deterioration (failure to rescue).
Reflecting/Evaluation: evaluate outcomes and learn from practice; adjust care plans as needed.
Distinctions:
Critical thinking is primarily classroom-based and knowledge-driven.
Clinical judgment occurs in real-time at the bedside; it translates theory into action.
Why this matters:
Clinical judgment is essential to prevent deterioration and to deliver safe, proactive care.
Encourages proactive rather than reactive nursing care; emphasizes asking why and understanding the rationale behind each action.
Practical implications:
The nursing process and Tanner’s model are intertwined with documentation, assessment, and decision-making across all stages of care.
Emphasis on developing patterns, cues, and reasoning to support accurate diagnoses and effective interventions.
Types of Nursing Diagnoses and Writing Diagnostic Statements
Types of nursing diagnoses:
Actual (problem-focused): describes a current patient problem needing nursing care (e.g., Acute Pain; Impaired Gas Exchange).
Risk for (at risk for a problem): no current problem but high risk (e.g., Risk for Falls; Risk for Impaired Skin Integrity).
Syndrome: a cluster of nursing diagnoses that tend to occur together and are addressed with a common set of interventions (e.g., Chronic Pain Syndrome).
Health promotion (wellness): readiness to enhance well-being (e.g., Readiness for Enhanced Family Coping).
Relation to medical diagnoses:
Medical diagnoses describe disease processes and are typically treated by physicians; nursing diagnoses describe human responses and guide nursing interventions.
The medical diagnosis can be used to inform the etiologies and pathophysiology when writing a nursing diagnosis, but it cannot replace the nursing diagnosis itself.
Four-part diagnostic statement (preferred in many teaching scenarios):
Structure:
Example format (with guidance):
Pain related to surgical incision secondary to abdominal surgery as evidenced by patient reports of pain 7/10 and facial grimacing when moving the affected area.
Three-part vs. four-part formats:
Three-part:
Two-part: for risk diagnoses where no defining characteristics are yet present.
Using medical dx to guide nursing dx:
When a patient has a documented medical diagnosis (e.g., MI), you can look up related nursing diagnoses (e.g., Decreased Cardiac Output) and align etiology and evidence accordingly.
If a medical dx is not present, you can still formulate a nursing diagnosis using the patient’s data and clinical reasoning.
Defining characteristics/evidence:
Evidence consists of signs and symptoms gathered during assessment (subjective and objective data) that support the diagnosis.
Common examples discussed in class:
Actual: Impaired Gas Exchange; Decreased Cardiac Output; Acute Pain; Impaired Skin Integrity; Impaired Mobility.
Risk for: Risk for Impaired Gas Exchange; Risk for Falls; Risk for Impaired Tissue Integrity.
Syndrome: Chronic Pain Syndrome; others as relevant to complex presentations.
Writing and Prioritizing Nursing Diagnoses
Priority setting in nursing diagnoses:
Primary emphasis on actual problems first, then high-risk diagnoses, then possible diagnoses.
If there are multiple problems, rank by severity and immediacy (ABC: Airway, Breathing, Circulation) and Maslow’s hierarchy of needs.
Using spirit of case examples:
Example: Post-op hip replacement with pain, limited mobility, and skin integrity concerns.
You can choose either impair mobility or impaired skin integrity as the primary diagnosis depending on which is most pressing; both are valid and can be addressed in the care plan.
Documentation and standards:
Documentation should use standardized terminology (NANDA, NIC, NOC, etc.) and be precise and specific to the patient.
Some healthcare settings use electronic care plans and guidelines (e.g., Epic) that incorporate NIC interventions and standardized pathways.
Planning: Goals, Interventions, and Outcomes
Planning stages:
Initial planning: begins on admission; discharge planning starts early in the process.
Ongoing planning: updates to care plans as the patient progresses.
Formalized care plans: standardized across a unit or hospital (protocol-driven); often embedded in electronic health records.
Individualized care plans: tailored to the specific patient’s needs, goals, and preferences.
Goals (SMART framework):
Specific: clear, concise statement of the target
Measurable: quantifiable or observable endpoint
Attainable: realistically achievable for the patient
Relevant: meaningful to the patient’s condition and needs
Time-bound: includes a timeframe for achieving the goal
Client-centered goals:
The patient or family must participate in goal setting for relevance and adherence.
Short-term vs. long-term goals:
Short-term goals: achievable within hours to days (e.g., regain the ability to perform a task with assistance).
Long-term goals: targeted by discharge planning (e.g., return to normal activities by a specified timeframe).
Interventions (types):
Independent nursing interventions: actions nurses can perform without a physician’s order (e.g., repositioning, breathing exercises, patient education).
Dependent nursing interventions: require a physician or advanced practice order (e.g., medications, certain therapies, wound care changes).
Collaborative interventions: involve other disciplines (PT/OT, dietitian, respiratory therapy, social work) and coordination of care.
Selecting and writing interventions:
Interventions should be specific to the patient’s goals and data; avoid vague actions.
Each intervention should include a rationale (why this is done) and a time frame for performance.
In practice, NIC (Nursing Interventions Classification) and other standardized taxonomies provide suggested interventions and rationales; however, you should tailor them to the patient.
Practical notes:
Some care plans are standardized for common surgeries (e.g., hip or knee replacement), offering protocol-based steps; always adapt for the individual patient when necessary.
Documentation should reflect who is responsible for each intervention (nurse, CNA, PT/OT, etc.) and how often tasks are performed.
Example of a complete planning snippet:
Problem: Impaired Mobility related to post-surgical pain and immobilization devices as evidenced by limited leg strength and patient report of pain when attempting to move.
Short-term goal: The patient will stand from bed with the assistance of a walker within 1 day.
Long-term goal: The patient will walk 20 feet with the assistance of a walker by day 7.
Interventions (examples):
Nurse will assess pain level and O2 saturation every 2 hours and as needed; administer analgesics as prescribed; encourage and assist with early mobilization; collaborate with PT/OT for gait and transfer training; ensure proper use of assistive devices; monitor wound/incision quality; provide nourishment and hydration support.
Rationale: Early mobilization reduces risk of pneumonia and thromboembolism; pain control enables participation in therapy; nutrition supports healing; PT/OT improves functional outcomes.
Implementation and Evaluation
Implementation: putting the plan into action
Execute nursing interventions as planned, with attention to safety, accuracy, and patient dignity.
Use delegation appropriately (CNA, LPN, etc.) and supervise when needed.
Document actions and patient responses; maintain a clear record for continuity of care.
Reassessment during implementation:
Reassess the patient to determine whether interventions are achieving the goal (e.g., check respiratory status after diuresis or evaluate wound healing after dressing changes).
Adjust care plans as patient status changes; add or modify interventions as needed.
Evaluation: determining outcomes and next steps
Compare actual outcomes to goals using measurable data (e.g., vital signs, lab values, functional outcomes).
Decide if goals were met, partially met, or not met:
If met: consider discontinuing the plan or moving to discharge planning.
If not met: modify interventions (and potentially revise goals) to better address the patient’s needs.
Documentation should include the conclusion and the supporting data that justify whether goals were met.
Quality and systems perspectives:
Nursing audits and quality improvement measures assess whether care delivered aligns with standards (falls prevention, infection prevention, wound care, medication safety).
Interprofessional collaboration and evidence-based practice drive continuous improvement in patient outcomes.
Example Scenarios and Applications
Myocardial Infarction (MI) case:
Assessment data (subjective and objective): chest pain radiating to the left arm, dyspnea, tachycardia, hypertension, ST elevations; troponin and CK-MB pending.
Potential nursing diagnoses:
Decreased Cardiac Output (actual) related to decreased coronary blood flow due to MI; evidenced by chest pain, tachycardia, ST changes, and elevated BP.
Example four-part statement:
Decreased Cardiac Output related to myocardial ischemia secondary to MI as evidenced by ST elevation, chest pain, tachycardia, and hypothetically low oxygen saturation.
Planning and interventions would emphasize airway/breathing, circulation, pain control, and tissue perfusion with timely revascularization as appropriate; involve ECG monitoring, labs, antiplatelet/anticoagulant therapy per protocol, and collaboration with the medical team.
Pneumonia case:
Assessment data: dyspnea, tachypnea, O2 sat 88% on 6 L nasal cannula, crackles on lung exam, productive cough with sputum.
Possible nursing diagnoses: Impaired Gas Exchange (actual) or Ineffective Airway Clearance (actual) or Risk for Impaired Gas Exchange (if early).
Example four-part statement: Impaired Gas Exchange related to alveolar edema and bronchial inflammation secondary to pneumonia as evidenced by O2 sat 88% on 6 L NC, tachypnea, crackles, and productive cough.
Planning and interventions would include oxygen therapy, incentive spirometry, airway clearance techniques, hydration, antibiotic therapy as prescribed, and consideration of respiratory therapy involvement.
Postoperative hip replacement:
Data: incision on the right hip, limited mobility, pain, possible skin integrity concerns.
Possible nursing diagnoses: Impaired Mobility; Impaired Skin Integrity; Acute Pain.
Example four-part statement: Impaired Mobility related to postoperative pain and immobilization devices as evidenced by limited leg strength and patient stating they cannot move independently.
Interventions: early mobility with PT/OT, walker-assisted transfer, pain management, incision care, nutrition optimization, and skin integrity monitoring.
Quick Tips for Study and Practice
Build a clinical binder with:
The nursing process steps (ADPIE) and Tanner’s four steps for quick review.
A quick reference for SMART goals, including examples and checklists.
A sheet of common NANDAs with brief definitions and example cues.
A small copy of the patient data collection forms or concept maps to practice cue clustering.
Practice writing one four-part nursing diagnosis per patient scenario and then expand to a second diagnosis if needed (prioritization exercise).
Use practice case studies to enhance cue clustering and pattern recognition.
Remember to involve patients in goal setting; ensure goals are realistic and relevant to their daily lives and discharge plans.
Always validate assessment data and use evidence-based rationales for interventions.
Quick References and Formulas (LaTeX)
The nursing process:
Tanner’s clinical judgment model: Noticing, Interpreting, Responding, Reflecting/Evaluation
SMART goals: SMART = ig\{S, M, A, R, T\big} with each component defined as Specific, Measurable, Attainable, Relevant, Time-bound
Diagnostic statement structure (four-part):
Notation for four-part examples can be adapted to three-part or two-part formats depending on data availability and risk status.
If you’d like, I can tailor these notes to a specific unit or provide one-page checklists for quick revision before the exam.