Critical thinking

Overview of Critical Thinking AndOverview of Critical Thinking And
Nursing ProcessNursing Process
(Fundamentals of Nursing)(Fundamentals of Nursing)
Palwasha khan
(BSN College of Nursing
NMU)

Definition
Critical thinking is an active, organized, cognitive process
used to carefully examine one’s thinking and the thinking of
others.
Purposeful, goal-directed thinking aiming to make
judgments based on evidence rather than conjecture. It is
based on principles of science & the scientific method &
develops strategies that maximize human potential &
compensates for problems caused by human nature

 Critical thinking is the process of intentional
higher level thinking to define a client’s problem,
examine the evidence-based practice in caring for
the client, and make choices in the delivery of care.
 Clinical reasoning is the cognitive process that
uses thinking strategies to gather and analyze client
information, evaluate the relevance of the
information, and decide on possible nursing actions
to improve the client’s physiological and
psychosocial outcomes.

Why do we need to think critically?
 Need to make accurate and appropriate clinical
decisions
 Need to solve problems and find solutions
 Need to plan care for each unique client and client
problem
 Need to seek knowledge and use it to make
clinical decisions and problem solving
 Need to be able to think creatively when planning
care for clients

Purpose of Critical thinking
The use of creativity provides the nurse with the ability to:
 Generate many ideas rapidly.
 Be generally flexible and natural; that is, able to change
viewpoints or directions in thinking rapidly and easily.
 Create original solutions to problems.
 Be independent and self confident, even when under
pressure.
 Demonstrate individuality.

Techniques in critical thinking
These techniques include:
 Critical analysis,
 Inductive and deductive reasoning,
 Making valid inferences,
 Differentiating facts from opinions, evaluating the
credibility of information sources,
 Clarifying concepts, and recognizing assumptions.

Applying critical thinking in
Nursing process
When a nurse uses intentional thinking, a relationship
Develops among the knowledge, skills, and attitudes that are
ascribed to critical thinking and clinical reasoning, the
nursing process, and the problem-solving process

PROBLEM SOLVING &
APPROACHES TO PROBLEM
SOLVING

Problem Solving
 Problem solving is a mental activity in which a problem is
identified that represents an unsteady state. It requires the
nurse to obtain information that clarifies the nature of the
problem and suggests possible solutions.
 Throughout the problem-solving process the implementation
of critical thought may or may not be required in working
toward a solution (Wilkinson, 2012).
 The nurse carefully evaluates the possible solutions and
chooses the best one to implement.

Approaches to problem solving
 Trail and Error
 Intuition
 Research process

Trial and Error
 One way to solve problems is through trial and error,
in which a number of approaches are tried until a
solution is found.
 The use of trial-and-error methods in nursing care can
be dangerous because the client might suffer harm if an
approach is inappropriate.
 However, nurses often use trial and error in the home
setting due to logistics, equipment, and client lifestyle

Intuition
 Intuition is a problem-solving approach that relies on a
nurse’s inner sense. It is a legitimate aspect of a nursing
judgment in the implementation of care (Wilkinson, 2012).
 Intuition is the understanding or learning of things without
the conscious use of reasoning. It is also known as sixth
sense, hunch, instinct, feeling, or suspicion.
 As a problem-solving approach, intuition is viewed by some
people as a form of guessing and, as such, an inappropriate
basis for nursing decisions.
 However, others view intuition as an essential and legitimate
aspect of clinical judgment acquired through knowledge and
experience.

Research Process
 The research process, is a formalized, logical,
systematic approach to problem solving.
 The classic quantitative research process is most
useful when the researcher is working in a
controlled situation.
 Health professionals, often working with people in
uncontrolled situations, require a modified
approach for solving problems.

ATTITUDES THAT FOSTER
CRITICAL THINKING

 Certain attitudes are crucial to critical thinking.
 These attitudes are based on the assumption that a rational
person is motivated to develop, learn, grow, and be concerned
with what to do or believe.
 A critical thinker works to develop the following nine attitudes
or traits:
1) Independence,
2) Fair-mindedness,
3) Insight,
4) Intellectual humility,
5) Intellectual courage,
6) Integrity,
7) Perseverance,
8) Confidence,
9) and Curiosity.

COMPONENTS OF CLINICAL
REASONING:

 Clinical reasoning is the analysis of a clinical situation as it
unfolds or develops. It requires the nurse to use cognitive and
metacognitive processes.
 Cognitive processes are the thinking processes based on
the knowledge of aspects of client care. Cognitive skills are
learned through reading and applying health-related
literature.
 Metacognitive processes include reflective thinking and
awareness of the skills learned by the nurse in caring for the
client. The

 Reflection-Purposely thinking back or recalling a
situation to discover its purpose or meaning. Looking
back and reflecting on a client situation helps the nurse to
have insight and meaning in the situation.
 Reflection allows the nurse to look at a situation honestly
and do some self evaluation of the situation.
 When reflecting, important to remain open to new
information, knowledge, ways of doing things.

 Language- The ability to use language and express
yourself is a reflection of the ability to think
meaningfully. Nurses must be able to use language
effectively (clearly and precisely). When language is not
well developed and the spoken word is not clear and
distinct it is a sign of sloppy thinking.
 We must communicate (speak) clearly and distinctly with
all of those around us, peers, nurses, patients and
families. To critically think you must be able to organize
and focus your own thoughts.

 Intuition- To have an understanding of the
particulars in a situation without conscious
deliberation. It is an inner sensing about a situation.
 This ability to have intuition about clients come with
time and experience.
 Can not use only intuition must use all types of
knowledge, cognitive and emotional cues to assess
clients and seek more info. Nurses also need to be
aware of what they do not know, and seek help
appropriately

 Basic critical thinking- Here learner is still trusting
that the experts have the answer to every problem
and situation
 Thinking is concrete and based on book, principles,
rules, policies (whatever they can read or hear
about). Lots of following the step by step (doing
bed bath).
 At this point there is very limited ability to think
critically, resources include instructors, books, other
nurses.
 Caution- Don’t let relying on resources limit ability
to grow, use experiences, practice, and knowledge
to grow to next level of thinking.

 Complex Critical thinking As people grow and
become more independent thinkers the level of
critical thinking will grow. Slowly will rely less and
less on their resource people and think before asking
them, come up with the answers themselves.
 As growth occurs there is a realization that there can
be more than one alternative and perhaps solution.
 As nurses begin to think in more complex ways they
look at a problem from many more angles and start
weighing the risks vs benefits of each decision/
solution. They start developing the ability to be
creative, to think out of the box.

 Commitment-The nurse starts anticipating patient
needs independently. At this level, the nurse makes a
decision based on alternatives and then stands by the
decision. The nurse assumes accountability/
responsibility for the decision and evaluates that
decision.

Critical Thinking Competencies

 Scientific method is an approach to seeking truth or
verifying facts. SM is a formal way to approach a
problem plan a solution, test the solution, and come to a
conclusion. Science fair. Nurse might identify a problem
and seek answers with a formal approach (collecting data,
formulating a hypothesis, testing the hypothesis,
evaluating the results.

 Problem solving- Use problem solving all the time-
when problem is identified we seek information about the
problem and the information plus knowledge that we
already have to find solutions. Effective problem solving
means evaluating the solutions and deciding if we need to
try other solutions

 Decision making- This happens when there are
several options or courses of action that one might
take to solve a problem or take care of a situation.
 Decision making is an end point of critical thinking.
The pros/ cons or risks/benefits of each option is
weighed to make a final decision. If time is taken to
weigh each option appropriately then a well informed
decision will be the result

 Diagnostic reasoning- It is a process of
determining a client’s health status after
gathering data and making a clinical judgment.
Part of the process involves making inferences
given data such as s/s, lab data, behaviors
(Inference is the process of drawing conclusions
given related pieces of information or data)

 Clinical decision making- requires careful reasoning so
that the options for the best client outcomes are chosen on
the basis of the client’s condition and the priority of the
problem. Nurse identifies a problem by working with
client and then still working with client determines
priorities and nursing interventions that will best meet
goals of client.
 The nurse may need to select from a wide range of
options to meet goals. Clinical decision making can be
made for individual patients or groups of patients.

Nursing ProcessNursing Process

NursingNursing
AssessmentAssessment

Assessing
 Assessing is the systematic and continuous collection,
organization, validation, and documentation of data
 Nursing assessments focus on a client’s responses to a
health problem. A nursing assessment should include the
client’s perceived needs, health problems, related
experience, health practices, values, and lifestyles.
 To be most useful, the data collected should be relevant
to a particular health problem. Therefore, nurses should
think critically about what to assess.

 In 2008 The Joint Commission established a nursing
practice guideline stating that each client should have
an initial nursing assessment consisting of a history
and physical examination performed and documented
within 24 hours of admission as an inpatient.
 The registered nurse is responsible for the collection
of comprehensive data, including physical, functional,
psychosocial, emotional, cognitive, sexual, cultural,
age-related, environmental, spiritual/transpersonal,
and economic assessments.

Data Collection:
 Data collection is the process of gathering information
about a client’s health status. Data collection must be
both systematic and continuous to prevent the omission
of significant data and reflect a client’s changing health
status.
 A database contains all the information about a client;
it includes the nursing health history physical
assessment, primary care provider’s history and
physical examination, results of laboratory and
diagnostic tests, and material contributed by other
health personnel.

Types of Data:
 Subjective data, also referred to as
symptoms or covert data, are apparent only
to the person affected and can be described
or verified only by that person. Itching, pain,
and feelings of worry are examples of
subjective data.
 Objective data, also referred to as signs or
overt data, are detectable by an observer or
can be measured or tested against an
accepted standard. They can be seen, heard,
felt, or smelled, and they frequently, or
rarely and include such data as blood
pressure, level of pain, and age.

Sources of Data:
 Sources of data are primary or secondary.
 The client is the primary source of data.
 Family members or other support persons, other health
professionals, records and reports, laboratory and diagnostic
analyses, and relevant literature are secondary or indirect source.
Sources of data is given as:
 Client
 Support people
 Client report
 Literature review
 Healthcare professionals

Data Collection methods:
The principal methods used to collect data are:
1. Observing,
2. Interviewing, and
3. Examining.
Observing occurs whenever the nurse is in contact
with the client or support persons. Interviewing is
used mainly while taking the nursing health
history. Examining is the major method used in the
physical health assessment

Observing:
Observing is a conscious, deliberate skill that is
developed
through effort and with an organized approach.
Observing has two aspects:
a. Noticing the data and
b. Selecting, organizing, and interpreting the data

Example:
For example, a nurse walks into a client’s room and
observes, in the following order:
1. Clinical signs of client distress (e.g., pallor or
flushing, labored breathing, and behavior indicating
pain or emotional distress)
2. Threats to the client’s safety, real or anticipated (e.g.,
a lowered side rail)
3. The presence and functioning of associated equipment
(e.g., intravenous equipment and oxygen)
4. The immediate environment, including the people in
it.

Interviewing:
 An interview is a planned communication or a conversation
with a purpose, for example, to get or give information, identify
problems of mutual concern, evaluate change, teach, provide
support, or provide counseling or therapy.
 Rapport is an understanding between two or more people
There is three types of interviewing:
1. Focused interview
2. Directive interview
3. Non-Directive interview

 In a focused interview the nurse asks the client
specific questions to collect information related to the
client’s problem. This allows the nurse to collect
information that may have previously been missed
and yields more in-depth information
 Directive interview is highly structured and elicits
specific information. The nurse establishes the
purpose of the interview and controls the interview, at
least at the outset
 Nondirective interview, or rapport building
interview, the nurse allows the client to control the
purpose, subject matter, and pacing

Types of interview Questions
 Open ended questions
 Close ended questions
 Neutral questions
 Leading questions

Examining:
 The physical examination or physical assessment is a systematic
data collection method that uses observation (i.e., the senses of
sight, hearing, smell, and touch) to detect health problems.
 To conduct the examination, the nurse uses techniques of inspection,
auscultation, palpation, and percussion.
 The physical examination is carried out systematically. It may be
organized according to the examiner’s preference, in a
 head-to-toe approach or
 a body systems approach.
 The cephalocaudal or head-to-toe approach begins the examination
at the head; progresses to the neck, thorax, abdomen, and
extremities; and ends at the toes.
 The nurse using a body systems approach investigates each system
individually, that is, the respiratory system, the circulatory system,
the nervous system, and so on. During the physical examination, the
nurse assesses all body parts and compares findings on each side of
the body (e.g., lungs)

Organizing Data:
 The nurse uses a written (or electronic) format that
organizes the assessment data systematically. This is
often referred to as a nursing health history, nursing
assessment, or nursing database form.
 The format may be modified according to the client’s
physical status such as one focused on
musculoskeletal data for orthopedic clients.
 Three examples are Gordon’s functional health pattern
framework, Orem’s self-care model, and Roy’s
adaptation model.

Validating Data:
 Validation is the act of “double-checking” or verifying data to
confirm that it is accurate and factual. Validating data helps the
nurse complete these tasks:
1. Ensure that assessment information is complete.
2. Ensure that objective and related subjective data agree.
3. Obtain additional information that may have been overlooked.
4. Differentiate between cues and inferences.
5. Avoid jumping to conclusions and focusing in the wrong
direction to identify problems.

Documenting Data:
 To complete the assessment phase, the nurse records
client data. Accurate documentation is essential and
should include all data collected about the client’s
health status. Data are recorded in a factual manner
and not interpreted by the nurse.
 For example, the nurse records the client’s breakfast
intake (objective data) as “coffee 240 mL, juice 120
mL, 1 egg, and 1 slice of toast,” rather than as
“appetite good” (a judgment).
 A judgment or conclusion such as “appetite good” or
“normal appetite” may have different meanings for
different people. To increase accuracy, the nurse
records subjective data in the client’s own words,
using quotation marks.

Nursing DiagnosisNursing Diagnosis

Definition:
“A clinical judgment about individual,
family, or community responses to actual or
potential health problems , A nursing
diagnosis provides the basis for selection of
nursing interventions to achieve outcomes
for which the nurse has accountability.”

Status or types of Nursing Diagnosis
“Status of the nursing diagnosis refers
to the actuality or potentiality of the
problem/syndrome or the
categorization of the diagnosis as a
health promotion diagnosis”
(Herdman & Kamitsuru, 2014, p. 100).

Types/status of Nursing Diagnosis:
 Actual nursing diagnosis.
 Risk nursing diagnosis.
 Possible nursing diagnosis.
 Syndrome nursing diagnosis.
 Wellness nursing diagnosis.

Actual nursing diagnosis:
A clinical judgment about human
experience/responses to health conditions/life
processes that exist in an individual, family, or
community". An example of an actual nursing
diagnosis is: Sleep deprivation.

Examples:
 Decreased cardiac output related to decreased myocardial
contractility As manifested by Tachycardia , arterial heart
sound , changes in blood pressure.
 Impaired physical mobility related to pain in lower back As
manifested by decreased muscle strength.
 Hopelessness related to loss of social support as manifested by
apathy.
 Altered nutrition: less than body requirement related to loss of
appetite as manifested by nausea and vomiting.
 ineffective airway clearance related to accumulation of
secretions as manifested by altered breath sounds and shortness
of breath

Risk nursing diagnosis :
Describes human responses to health conditions that may
develop in a vulnerable individual. It is supported by risk
factors that contribute to increased vulnerability. An
example of a risk diagnosis is: Risk for shock.

Examples:
 Risk for injury related to loss of sensory perception as
evidenced by patient is blind at both eyes.
 Risk for infection related to compromised immune
system as evidenced by poor vaccination history
 Risk for suicide related to hopelessness, increased
anxiety, as evidenced by suicidal ideation, statements of
despair.

 Risk for decreased gastrointestinal circulation related to
acute gastrointestinal bleeding as manifested by blood in
stool.
 Risk for fall related to decreased physical capability as
manifested by weakness and dizziness.
 Risk for social isolation related to Absence of peers as
manifested by loneliness.

Possible nursing diagnosis:
A type of diagnosis in which evidence about a health
problem is not clear and requires more data either to
support or refuse it.

Example:
 Possible stress incontinence related to tissue trauma
during delivery as manifested by during exercising ,
sneezing and standing position
 Possible anxiety related to loss of spouse as
manifested by isolation.
 Possible decreased gastrointestinal motility related to
sedentary life style.

Wellness nursing diagnosis:
A clinical judgment about a person’s, family’s or
community’s motivation and desire to increase wellbeing
and actualize human health potential. E.g : Readiness for
enhanced nutrition'.‘

Example:
 Readiness for enhanced comfort as evidenced by express
desire to enhance relaxation
.
 Readiness for enhanced spiritual well being as
evidenced by express desire for prayer and mediation.
 Readiness for enhanced health mangment as
manifested by asking questions about therapeutic
regimen.

Syndrome nursing diagnosis:
 A clinical judgment describing a specific cluster of
nursing diagnoses that occur together, and are best
addressed together and through similar interventions."
An example of a syndrome diagnosis is: Rape trauma
syndrome.

Example:
There is only two syndrome diagnosis on the NANDA list
are:
- Rape trauma syndrome.
- Disuse syndrome.

Disuse syndrome includes cluster of diagnosis as:
Impaired physical mobility , risk for ineffective
tissue integrity, risk for activity intolerance , risk for
infection, Risk for constipation , risk for injury , risk
for powerlessness , risk for hopelessness

Components of nursing
diagnose:
 Problem (diagnostic label)
 Etiology
 Defining characteristics.

Nanda labels/qualifiers:
labels or Qualifiers are words that have been added to some
NANDA labels to give additional meaning to the diagnostic
statement, for example:
 Altered : A change from baseline.
 Impaired: made worse , weakened damaged.
 Decreased : smaller in size , amount or degree.
 Ineffective: Not producing the desired effects.
 Acute : sever or short of duration.
 Chronic: Lasting a long time , recurrent.
 Compromised (to make vulnerable to threat)

How to make Nursing
diagnosis:
Steps involves:
 Conduct a nursing assessment
 Cluster and interpret cues/patterns
 Generate Hypotheses.
 Validation & Prioritization of Nursing Diagnoses

Parts of diagnostic statement:
1- Two part statement includes:
- Problem
- Etiology
2- Three part statements:
- Problem
- Etiology
- Defining characteristics.

Problem Related to Etiology
1- Clonic
Constipation Related to Prolonged
laxative
use.
2- Ineffective Related to Breast
Breastfeeding Engorgement.

1- Self esteem disturbances related to rejection by
husband as manifested by Hypersensitivity to
criticism.
2- Impaired physical mobility related to pain in
lowerbackas manifested by decreased
muscle strength.

Errors occur in nursing
diagnosis
 Data Collection.
 Interpretation and analysis of data.
 In the diagnostic statement.

Scenario 1:
Mr Woods is admitted with COPD. He is short of
breath, anxious, cyanosed, confused and has a respiratory
rate of 40. All of these symptoms began yesterday when he
suddenly found it difficult to breath.
Medical diagnosis: COPD
Nursing Diagnosis?

Scenario 2:
Subjective data:
“I am suffering with the difficulty to eat and drink due
to sever throat pain associated with the pain and fever”
Objective data:
Temp : 101.2 F
Tonsils are swollen and skin is warm and poor turgor.
Medical Diagnosis: Tonsilitis
Nursing Diagnosis?

Scenario 3:
Mr. Nelson is 55 years old male admitted in the
hospital 24 hours ago , with the complain of sever
chest pain radiating to left arm and jaw , He has
shortness of breath and decreased pulse and Blood
pressure is 90/40 mmHg
Medical diagnosis: Myocardiatis.
Nursing diagnosis?

Planning:
 Planning is a deliberative, systematic
phase of the nursing process that
involves decision making and problem
solving.
 In planning, the nurse refers to the
client’s assessment data and diagnostic
statements for direction in formulating
client goals and designing the nursing
interventions required to prevent, reduce,
or eliminate the client’s health problems

 Planning begins with the first client
contact and continues until the nurse–
client relationship ends, usually when
the client is discharged from the health
care agency.
 All planning is multidisciplinary
(involves all health care providers
interacting with the client) and includes
the client and family to the fullest extent
possible in every step

Types of planning
 Initial planning
 Ongoing planning
 Discharge planning

Initial planning:
 Admission assessment based on the initial
care.
 As nurse obtains new information and
evaluate the client responses to care, they
can individualize the initial care further.

Ongoing planning:
 As nurses obtain new information and
evaluate the client’s responses to care,
they can individualize the initial care
plan further.
 Ongoing planning also occurs at the
beginning of a shift as the nurse plans
the care to be given that day.

 Using ongoing assessment data, the nurse carries
out daily planning for the following purposes:
1. To determine whether the client’s health status
has changed
2. To set priorities for the client’s care during the
shift
3. To decide which problems to focus on during the
shift
4. To coordinate the nurse’s activities so that more
than one problem can be addressed at each client
contact.

Discharge planning:
 Discharge planning, the process of
anticipating and planning for needs
after discharge, is a crucial part of a
comprehensive health care plan and
should be addressed in each client’s
care plan

Developing nursing care plan
 The end product of the planning phase of the
nursing process is a formal or informal plan of
care:
1. An informal nursing care plan
2. Formal nursing care plan
3. Standardized nursing care plan
4. An individualized nursing care plan

 An informal nursing care plan:
An informal nursing care plan is a strategy for action that exists in
the
nurse’s mind.
 Formal nursing care plan
A formal nursing care plan is a written or computerized guide that
organizes information about the client’s care. The most obvious
benefit
of a formal written care plan is that it provides for continuity of care.
 Standardized care plan
It is a formal plan that specifies the nursing care for groups of
clients
with common needs (e.g., all clients with myocardial infarction).
 Individualized care plan
It is tailored to meet the unique needs of a specific client—needs
that
are not addressed by the standardized plan.

Guidelines for writing nursing care plan:
1. Date and sign the plan
2. Use category heading
3. Use standardized/approved medical or English symbols and
key words rather than complete sentences to communicate your
ideas unless agency policy dictates otherwise
4. Be specific
5. Refer to procedure books or other sources of information rather
than including all the steps on a written plan
6. Ensure that the nursing plan incorporates preventive and health
maintenance aspects as well as restorative ones.
7. Ensure that the plan contains ongoing assessment of the client
8. Include collaborative and coordination activities in the plan.
9. Include plans for the client’s discharge and home care needs.

The planning process:
In the process of developing client care plans, the nurse engages in
the following activities:
1. Setting priorities
2. Establishing client goals/desired outcomes
3. Selecting nursing interventions and activities
4. Writing individualized nursing interventions on care plans.

1. Setting priorities:
 It is the process of establishing preferential sequence
for addressing the nursing diagnosis and intervention
 The client and nurse decides which nursing diagnosis
requires attention primarily and secondary and so on
 instead of rank ordering diagnosis, nurse can group
them as high, medium and low priority
 Requires minimal nursing support.

 High priority: Life-threatening problems, such as
impaired respiratory or cardiac function, are
designated as high priority.
 Medium priority: Health-threatening problems, such
as acute illness and decreased coping ability, are
assigned medium priority because they may result in
delayed development or cause destructive physical or
emotional changes.
 A low-priority problem is one that arises from normal
developmental needs or that requires only minimal
nursing support.

 Nurses frequently use Maslow’s hierarchy of needs
when setting priorities .
 In Maslow’s hierarchy, physiological needs such as
air, food, and water are basic to life and receive higher
priority than the need for security or activity. Growth
needs, such as self-esteem, are not perceived as
“basic” in this framework.
 Thus, nursing diagnoses such as Ineffective Airway
Clearance and Impaired Gas Exchange would take
priority over nursing diagnoses such as Anxiety or
Ineffective Coping

The nurse must consider the following factors
when assigning priorities given as:
1. Client’s health values and beliefs
2. Client’s priorities
3. Resources available to the nurse and client
4. Urgency of health problem
5. Medical treatment plan

2. Establishing client goals and desired outcomes:
 After establishing priorities, the nurse and client set
goals for each nursing diagnosis.
Goal (broad): Improved nutritional status.
Desired outcome (specific): Gain 5 lb by April 25.
 When goals are stated broadly, as in this example, the
care plan must include both goals and desired
outcomes. They are sometimes combined into one
statement linked by the words “as evidenced by,” as
follows:
Improved nutritional status as evidenced by weight
gain of 5 lb by April 25.

Purpose of goals or desired outcome:
1. Provide direction for planning nursing
interventions.
2. Serve as criteria for evaluating client progress.
3. Enable the client and nurse to determine when the
problem has been resolved.
4. Help motivate the client and nurse by providing a
sense of achievement.

Short term and long term Goals:
 Goals may be short term or long term. A short-term
goal might be “Client will raise right arm to shoulder
height by Friday.” In the same context, a long-term
goal/outcome might be “Client will regain full use of
right arm in 6 weeks.”
 Short-term goals are useful for clients who
(a) require health care for a short time or
(b) are frustrated by long-term goals that seem
difficult to attain
 However, clients in acute care settings also need long-
term goals/outcomes to guide planning for their
discharge to long-term agencies or home care,
especially in a managed care environment.

3. Selecting nursing interventions and
activities:
Types of nursing interventions:
 Independent interventions: activities that the nurses
are licensed to initiate i.e. physical care, ongoing
assessment counseling, emotional support,
environmental management.
 Dependent interventions: activities carried out
under physician order I.e. medication, diagnostic test,
dietary intake.
 Collaborative interventions: nurses carried out in
collaboration with other team members such as
physiotherapies, social workers, dietitians, physicians
etc.

Implementation andImplementation and
Evaluation phaseEvaluation phase

Implementation:
 Using Nursing Interventions Classification (NIC)
terminology, implementing consists of doing and
documenting the activities that are the specific nursing
actions needed to carry out the interventions.
 The nurse performs or delegates the nursing activities
for the interventions that were developed in the
planning step and then concludes the implementing
step by recording nursing activities and the resulting
client responses

 recording nursing activities and the resulting client
responses. The fifth standard of the American Nurses
Association (ANA) Standards of Practice is
implementation.
 Three of the implementation substandards apply to all
registered nurses: coordination of care, health teaching
and health promotion, and consultation. The fourth
substandard, prescriptive authority and treatment,
applies only to advanced practice nurses (ANA, 2010).

Implementation skills:
To implement the care plan successfully,
nurses need:
 Cognitive skills
 Interpersonal skills
 Technical skills.

 The cognitive skills (intellectual skills) include problem
solving, decision making, critical thinking, clinical
reasoning, and creativity. They are crucial to safe,
intelligent nursing care
 Interpersonal skills are all of the activities, verbal and
nonverbal, people use when interacting directly with
one another
 Technical skills are purposeful “hands-on” skills such
as manipulating equipment, giving injections,
bandaging, moving, lifting, and repositioning clients.

The implementation process:
 The process of implementing normally
includes the following:
1.Reassessing the client
2.Determining the nurse’s need for
assistance •
3.Implementing the nursing interventions •
4.Supervising the delegated care
5.Documenting nursing activities.

1. Reassess the client:
 Just before implementing an intervention, the nurse
must reassess the client to make sure the intervention is
still needed. Even though an order is written on the
care plan, the client’s condition may have changed.
 For example, a client has a nursing diagnosis of
Disturbed Sleep Pattern related to anxiety and
unfamiliar surroundings. During rounds, the nurse
discovers that the client is sleeping and therefore defers
the back massage that had been planned as a relaxation
strategy.

2. Determining the nurse’s need for assistance:
When implementing some nursing interventions, the nurse may
require
assistance for one or more of the following reasons:
 The nurse is unable to implement the nursing activity safely or
efficiently alone (e.g., ambulating an unsteady obese client).
 Assistance would reduce stress on the client (e.g., turning a
person who experiences acute pain when moved).
 The nurse lacks the knowledge or skills to implement a particular
nursing activity (e.g., a nurse who is not familiar with a particular
model of traction equipment needs assistance the first time it is
applied).

3. Implementing the nursing interventions
When implementing nurse should follow these guidelines:
 Base nursing interventions on scientific knowledge, nursing research,
and professional standards of care whenever is possible,
 Nurse must know scientific rational and side effects or complications of
all intervention e.g. drugs before meals
 Clearly understands the order to be implemented and question any that
are not understood.
 Adopt activities to the individual client
 Provide teaching, support and comfort
 Be holistic
 Respect the dignity of client and enhance self esteem
 Encourage client to participate actively In implementation

4) Supervise delegated care:
If care has been dedicated to other healthcare
personnel the nurse responsible for all the client care
must ensure that the activities have been implemented
according to the care plan
5) Documenting Nursing activities:
The nurse completes the intervention phase by
recording the interventions and client response in the
nursing process note.

 The nurse may record routine or recurring activities
such as mouth care in the client care at the end of the
shift, while some actions are recorded in the special
work sheets according to agency policy
 Immediate recording helps to safeguard the client to
prevent double action.

Evaluation phaseEvaluation phase

Evaluation:
 Evaluation is a planned, ongoing, purposeful activity
in which clients and health care professionals
determine (a) the client’s progress toward achievement
of goals/ outcomes and (b) the effectiveness of the
nursing care plan.
 The last phase of the nursing process follows
implementation is the evaluation of the plan of care.
 It is the judgment of the effectiveness of the nursing
care to meet client goals based on client’s behavioral
responses.

Characteristics of evaluation:
 Evaluation is continuous
 Done immediately after implementation to make on
the spot medications in an intervention.
 Evaluation performed at specified intervals.
 Evaluation continues until the client achieves the
health goals or discharged from nursing care
 Evaluation includes goal achievement and self-care
abilities
 Through evaluation nurses demonstrate responsibility
accountability for their actions, indicate in the result of
the nursing activities.

Process of evaluating client responses
1) Collecting data related to the desired outcome
2) Comparing the data with the outcome
3) Relating nursing activities to outcome
4) Drawing conclusions about problem status
5) Continuing, modifying., or terminating the nursing care plan

When determining whether a goal has been achieved, the
nurse can draw one of the three possible conclusions:
 The goal was met, that is the client response is the same as the
desired outcome.
 The goal was partially met, that is either a short term goal was
achieved but the long term was not, or the desired outcome was
only partially achieved.
 The goal was not met

Documenting andDocumenting and
ReportingReporting

DOCUMENTATION
 Any printed or written record of activities.
 Recording and reporting are the major ways
health care providers communicate.
 The client’s medical record is a legal
document of all activities regarding client
care.

 Documentation: serves as a permanent
record of client information and care
 Reporting: Take place when two or
more people share information about
client care either face to face or on
telephone

Types of Medical records:
 Patient identification and demographic data
 Present complains
 Informed consent for treatment and procedures
 Admission nursing history
 Family history
 Physical examination finding
 Medical history
 Final diagnosis
 Patient education
 Nursing care plan
 Kardexes
 Daily treatment and procedures
 Flow chart
 Fluid balance record
 Medication’

PRACTICE AND LEGAL
STANDARDS
The legal aspects of documentation
require:
 Writing legible and neat
 Spelling and grammar properly used
 Authorized abbreviations used
 Time-sequenced factual and descriptive
entries

PRACTICE STANDARDS INCLUDE:
 State Nursing Practice Acts
 Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)
 Confidentiality
 Informed consent
 Advance Directives

Purposes of
Client’s Record
Chart1.1. Communication.Communication. Provides efficient andProvides efficient and
effective method of sharing information.effective method of sharing information.
2.2. Legal Documentation.Legal Documentation. It is admissible asIt is admissible as
evidence in a court of law.evidence in a court of law.
3.3. Research.Research. Provides valuable health-related dataProvides valuable health-related data
for research.for research.
4.4. Statistics.Statistics. Provides statistical information thatProvides statistical information that
can be utilized for planning people’s futurecan be utilized for planning people’s future
needs.needs.
5.5. Education.Education. Serves as an educational tool forServes as an educational tool for
students in health discipline.students in health discipline.

6.6. Audit & Quality Assurance.Audit & Quality Assurance. Monitors theMonitors the
quality of care received by the client andquality of care received by the client and
the competence of health care givers.the competence of health care givers.
7.7. Planning Client Care.Planning Client Care. Provides data whichProvides data which
the entire health team uses to plan care forthe entire health team uses to plan care for
the client.the client.
8.8. Reimbursement.Reimbursement. Provides the basis forProvides the basis for
decisions regarding care to be provided anddecisions regarding care to be provided and
subsequent reimbursement to the agency,subsequent reimbursement to the agency,
to cover health-related expenses.to cover health-related expenses.

NURSING AUDIT
 Method of evaluating the quality of care
 Includes:
– Safety measures
– Treatment interventions and responses
– Expected outcomes
– Client teaching
– Discharge planning
– Adequate staffing

PRINCIPLES OF EFFECTIVE
DOCUMENTATION
1. Document accurately, completely, and
objectively, including any errors.
2. Note date and time.
3. Use appropriate forms.
4. Identify the client.
5. Write in ink.
6. Use standard abbreviations.

7. Spell correctly.
8. Write legibly.
9. Correct errors properly.
10. Write on every line.
11. Chart omissions.
12. Sign each entry.

Two types of Recording:
 Source oriented Medical Records
 Problem oriented Medical Records

1. SOURCE ORIENTED MEDICAL RECORD
NARRATIVE CHARTING (TRADITIONAL CLIENT
RECORD)
▫ Most flexible of all methods and is usable in any
clinical setting.
• Five Basic components of a Traditional Client Record
 admission sheet
 physician’s order sheet
 Medical history
 Nurse’s notes
 Special records and reports (referrals, X-ray,
reports, laboratory findings, report of surgery,
anesthesia record, flow sheets, vital signs, I&O,
Medications)

2. Problem-Oriented medical record (POMR or
POR)
– The record integrates all data about the problem,
gathered by the members of the health team.
FOUR BASIC COMPONENTS OF POMR/POR
1. Database.
2. Problem list.
3. Initial list of orders or care plans.
4. Progress notes:
◦ Nurse’s or narrative notes (SOAPIE format)Nurse’s or narrative notes (SOAPIE format)
Subjective, Objective, Analysis, Planning,Subjective, Objective, Analysis, Planning,
Intervention, EvaluationIntervention, Evaluation
◦ Flow sheets (data that are monitored)Flow sheets (data that are monitored)
◦ Discharge notes or referral summariesDischarge notes or referral summaries

System ofSystem of
DocumentationDocumentation

SYSTEMS OF DOCUMENTATION
 Narrative charting
 Source-oriented charting
 Problem-oriented
charting
 PIE charting
 Focus charting
 Charting by exception
 Computerized
documentation
 Critical pathways

NARRATIVE CHARTING
 Traditional method of nursing documentation.
 Chronologic account in paragraphs describing
client status, interventions and treatments, and
client’s response.
 The most flexible system.
 Usable in any clinical setting.

SOURCE-ORIENTED CHARTING
 Narrative recording by each member of the
health care team on separate documents.

PROBLEM-ORIENTED CHARTING
 SOAP, SOAPI, AND SOAPIER
– S: subjective data
– O: objective data
– A: assessment data
– P: plan
– I: implementation
– E: evaluation
– R: revision

PIE CHARTING
 P: problem
 I: intervention
 E: evaluation

FOCUS CHARTING
 System using a column format to chart Data,
Action, and Response (DAR).

CHARTING BY EXCEPTION
 Only significant findings (exceptions) are
documented in a narrative form.
 Presumes that unless documented
otherwise, all standardized protocols have
been met and no further documentation is
needed.

COMPUTERIZED
DOCUMENTATION
 Reduces time taken, increases accuracy.
 Increases legibility.
 Stores, retrieves information quickly.
 Improves communication among health care
departments.
 Confidentiality and costs can be problems.

CRITICAL PATHWAY
 Also known as Care Maps.
 Comprehensive pre-printed standard plan
reflecting ideal course of treatment for
diagnosis or procedure, especially with
relatively predictable outcomes.
 Additional forms are needed to complement
the pathway.

NURSE’S PROGRESS NOTES
 Document client’s condition, problems,
complaints, interventions, and client’s
response to interventions.
 Include MAR, vital signs records, flow
sheets, and intake and output forms.

DISCHARGE SUMMARY
 Client status on admission and discharge
 Brief summary of the client’s care
 Intervention and education outcomes
 Resolved and unresolved problems
 Client instructions about medications, diet,
food-drug interactions, activity, treatments,
follow-up, and other needs

Kardex
Provides a concise method of organizing and recording
data about a client, making information readily
accessible to all members of the health team
It is a series of flip cards usually kept in portable file
It is a way to ensure continuity of care from one shift to
another and from one day to the next
It is a tool for change – of – shift report. But
endorsement is not simply reciting content of kardex.
Health care needs of the client is still primary basis for
endoresement.

 Usually include the ff. data:
– Personal data
– Basic needs
– Allergies
– Diagnostic tests
– Daily nursing procedures
– Medications and intravenous (IV) therapy, blood
transfusions
– Treatments like oxygen therapy, steam inhalation,
suctioning, change of dressings, mechanical
ventilation.
 Entries usually written in pencil. This implies the
kardex is for planning ang communication purpose
only.

GENERAL DOCUMENTATION
GUIDELINES
* Ensure that you have the correct client record or chart.
* Document as soon as the client encounter is concluded to
ensure accurate recall of data.
* Date and time of each entry.
* Sign each entry with your full legal name and with your
professional credentials.
* Do not leave space in between entries.
* If an error is made while documenting, use a single line to
cross out the error, then date, time and sign the correction
* Never change another person’s entry even if it is incorrect
* Use quotation marks to indicate direct client responses.
* Document in chronological order
* Use permanent ink
* Document all telephone calls that you received that are
related to client’s case.

Characteristic of Good Recording:
• BREVITY
– Entries are concise
– Complete sentences are not required
– Start each entry with a capital letter and end the entry
with a period even if the entry is a single word or
phrase.
• USE INK/PERMANENCE
– Avoid pencil for permanence of data, because the
client’s chart can be used as an evidence in a legal
court.

• ACCURACY
– Chart objective facts, not your interpretations or
opinions
– Eg.
Ate 50% of the food served.
Ate with poor appetite.
Refused medications.
Uncooperative.
Seen crying.
Depressed.

– Place complaint of the client in
quotation marks to indicate that it
is his statement.
“chest pain radiating down the left arm”
“nahihirapan akong huminga kapag
nakahiga”
– Objective data are also to be
charted.
E.g. skin cold and clammy. Diaphoretic.
Prefers to sit up. Vital signs taken as
follows: temp-37.6C, PR-110/min.,
RR-26/min. BP-140/90 mmHg.

– Describe behaviors rather than feelings to allow other
health team members to determine the actual
problems of the client.
– Refusal of medications and treatments must be
documented.
• APPROPRIATENESS
– Only information that pertains to the client’s health
problems and care are recorded.
– Any other personal information that is conveyed to
the nurse is appropriate for the record.

– takes place when two or more people share information
about client care , either face to face or by telephone.
Types of reporting
 Walking rounds
change – of – shift reports or
endorsement
– for continuity of care
– it is based on health care needs of the client
– it is not mere reciting the content of the kardex
 Telephone reporTs
– provide clear accurate and concise information
– the nurse documents telephone report by including the following
information:
• when the call was made
• who made the call/report
• who was called
• to whom information was given
• what information was given
• what information was received

 Telephone orders
– Only RN’s may receive telephone orders
– The order need to be verified by reporting it clearly
and precisely.
– The order should be countersigned by the physician
who made the order within the prescribed period of
time (within 24 hours)
 Transfer reports
– this is done when transferring a client from unit to
another.
 Incident Reports or occurrence
reports
– Used to document any unusual occurrence
or accident in the delivery of client care

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