Chapter 1
Overview of Nursing Process,
Clinical Reasoning, and Nursing
Practice Today
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
• Is the following statement true or false?
• Nursing process is a linear process.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• False
• Rationale: The nursing process is a cycle rather than a
linear process.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process
• Foundation for clinical reasoning
• Required by national practice standards
• Tested on NCLEX
• First tool “to think like a nurse”
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process (cont.)
• Cycle
• Not a linear process
• Purposeful
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
• What are the phases of the nursing process?
– 1. Assessment
– 2. Diagnosis
– 3. Planning
– 4. Implementation
– 5. Evaluation
• A. 1, 2, and 4
• B. 1, 3, 4, and 5
• C. 1, 2, 3, and 4
• D. 1, 2, 3, 4, and 5
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• D. 1, 2, 3, 4, and 5
• Rationale: The five phases of the nursing process are
assessment, diagnosis, planning, implementation, and
evaluation.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Phases in Nursing Process
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Assessment
• Collect and record all the information to:
– Predict, detect, prevent, and manage actual and
potential health problems
– Promote optimum health, independence, and wellbeing
– Clarify expected outcomes (results)
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Diagnosis
• Analyze the data you gathered, draw conclusion, and
determine whether there are:
– Risks for safety or infection transmission (deal with
these immediately)
– Signs or symptoms that need evaluation by a more
qualified professional (report these immediately)
– Actual and potential health problems requiring
nursing or medical management
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Diagnosis (cont.)
• Risk factors requiring nursing or medical management
• Issues that aren’t quite clear, but require further
investigation
• Learning needs that must be addressed
• Patient resources, strengths, and use of healthy
behaviors
• Health states that are satisfactory but could be improved
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Planning
• Clarify expected outcomes (results), set priorities, and
determine interventions (nursing actions). The
interventions are designed to:
– Detect, prevent, and manage health problems and
risk factors
– Promote optimum function, independence, and sense
of well-being
– Achieve the expected outcomes safely and efficiently
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Implementation
• Put the plan into action.
– Assess the patient to determine current status—
decide whether the patient is ready and the
interventions are still appropriate.
– Perform the interventions (nursing actions).
– Reassess the patient to determine end results
(outcomes).
– Make immediate changes as needed.
– Chart nursing actions and patient responses.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Evaluation
• Do a comprehensive patient assessment to decide
whether expected outcomes have been met or whether
new problems have emerged.
– Decide whether to modify or terminate the plan.
– Plan for ongoing continuous assessment and
improvement.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Keys Things to Remember
• Nursing process phases
– Overlap
– Interrelated
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Accuracy of Nursing Process Steps
• Good communication skills
• Factual
• Relevant
• Comprehensive assessment data
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process and Nursing Activities
• Formal care planning
• Documentation
• Guide for thinking at the point of care every day
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
• Is the following statement true or false?
• Critical thinking is a broad term that includes clinical
reasoning.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• True
• Rationale: The terms critical thinking and clinical
reasoning are often used interchangeably. Critical thinking
is a broad term that includes clinical reasoning.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Critical Thinking and Clinical Reasoning
• Often used interchangeably
• Critical thinking is a broad term that includes clinical
reasoning.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical Reasoning
• Specific term
• Assessment and management of patient problems at the
point of care
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Critical Thinking
• Promoting teamwork and streamlining work flow
• Reasoning other issues, besides assessment, and
management of patient problems
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Complements Other Health Care Workers
• Focusing on both medical problems and on the impact of
medical problems and treatment plans on patients’ lives
• Aims to promote health
– Maximizing independence
– Sense of well-being
– Ability to function regardless of presence of illness or
disability
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Application of Nursing Process
• Requires application
– National and state laws
– Local policies and procedures
• Follows ethics codes and principles.
• Applies a code of conduct.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Competent in the Use of Nursing Process
• Develop critical thinking behaviors
• Strong interpersonal and technical skills
• Be willing and able to care
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins