A Student’s Guideline to Using
the Critical Thinking Rubric to
meet the Performance Objectives
in Developing Nursing Care
Plans
Suffolk Community College
School of Nursing
Susan McCabe
A Continuation of the Project Plan from the Summer Institute the
TITLE III grant: “The Development of the Critical Thinking Rubric to
Analyze Nursing Care Plans”
What Are the
Characteristics of an
Excellent Nursing
Care Plan?
There are three characteristics
that distinguish excellent
student performers from their
peers.
CHARACTERISTICS OF
AN EXCELLENT NCP
Evidences adequate
inquiry, research and
use of best resources.
CHARACTERISTICS OF
AN EXCELLENT NCP
Deduces the most
accurate human
response (diagnostic
label) from the data
collected.
CHARACTERISTICS OF
AN EXCELLENT NCP
Analyzes the human
responses and selects
the the diagnostic
labels that would have
the greatest impact on
the client’s outcome.
Meeting the behavioral objective:
Evidences adequate
inquiry, research and
use of best resources.
How can the student achieve this
objective?
The groundwork for an excellent
care plan begins with the
utilization of inquiry, research
and resources at the clinical site.
It begins in preconference when
the student receives report.
Preconference exercise
You receive report on the following client:
79 y/o female admitted for pneumonia,
exacerbation of COPD who has CHF
by history with the following orders:





nasal cannula oxygen at 2 lpm
albuterol drug nebs q 4hrs and q 2 hours prn
IV D51/2 NS at 75 cc/hr
Solumedrol 80 mg IVP q 6 hrs
ABG’s on room air and electrolytes to be drawn
this AM.
Exercise your
inquiry,research and best
resources.
Reflect on knowledge and skills
79 y/o female admitted for pneumonia,
exacerbation of COPD who has CHF by history
with the following orders:
 nasal cannula oxygen at 2 lpm
 albuterol drug nebs q 4hrs and q 2 hours prn
 IV D51/2 NS at 75 cc/hr
 Solumedrol 80 mg IVP q 6 hrs
 ABG’s on room air and electrolytes to be drawn
this AM.
ASK YOURSELF WHO, WHAT WHY,
WHERE, WHEN AND HOW?
Identify your best resources and
references
What handbooks would you access
immediately to prepare for caring
for your client?
How can each resource facilitate the
attainment of knowledge and skills?
•
•
•
•
•
MED/SURG handbook
drug reference
lab test reference
nursing diagnosis handbook
hospital procedure manual
Develop a plan to evidence
adequate inquiry and assess your
client.
Initial client assessment:
LOC: level of consciousness
A:
airway
B:
breathing
C:
circulation/bleeding
I/O:
everything going in/out
wound:what does it look like?
Pain: present? Scale? Treatment?
safety: bed low? Call bell? Siderail?
After performing the initial
assessment, gather any
additional information you need
from the chart and return to
perform a focused assessment.
The Interview
SPECIFIC
QUESTIONS
RELATED TO
THE CHIEF
COMPLAINT
AND RELATED
SYSTEMS
The Interview
Interview questions should identify
the client’s response to their
situation
should include both positive and
negative findings that you might
suspect a client experiencing those
stressors could experience
record all the clients responses
using all available space
APPROACH TO EXAM
DO YOUR ABC's, THEN
– INSPECTION
– PALPATION
– PERCUSSION
– AUSCULTATION
Don’t just fill in the blanks….
Use all available space to
communicate the pertinent
findings integrating the health
assessment framework.
Seek clarification
Check your findings against the
what has been previously recorded
for the client…..
a variation in the client’s status should
be clarified with your best resource on
the unit……
your clinical instructor.
Develop a narrative that
reflects the “thinking and
doing” of the nurse:
the assessment, actions
and client response.
Clarify significance of data,
actions and client response in
post-conference.
Organize your data to
perform additional research
to prepare the NCP.
Assessment form
daily nursing process plan
lab data results sheet
medication sheets
INQUIRY, RESEARCH,
SOURCES
RESEARCH THE SUBJECTIVE AND
OBJECTIVE DATA UNTIL YOU OWN
THE MATERIAL.
DON’T PUT ANYTHING ON PAPER
THAT YOU CAN NOT EXPLAIN IN
YOUR OWN WORDS.
Develop a reference list
IDENTIFY THE BEST RESOURCES TO
FACILITATE YOUR
UNDERSTANDING.
 Instead of compiling a list of resources
that you think are relevant….
Read the references and decide which help
you to grasp the meaning of the client’s
situation.
Use a systematic approach to
develop a priority list. Challenge
assumptions from your research
and place it in the context of
your client’s unique response.
What is the source of the
client’s unique response?
Assessment form
daily nursing process plan
lab data results sheet
medication sheets
What is the priority list?
A list of diagnostic labels
each label conforms to PES
format
developed from the
systematic analysis of all the
relevant data
Where do I begin?
Begin with the stressors that
the client is currently
experiencing.
Consider continuing stressors
that the client faces that
influence their adaptation to the
stressor precipitating the
current admission.
What are the stressors?
Examine the following:
– admitting diagnosis
– previous medical history
– previous medications
– current medications
– current therapies
– current procedures
CAN YOU IDENTIFY ANY
COLLABORATIVE PROBLEMS THAT
THE CLIENT MAY BE EXPERIENCING?
Accurate nursing diagnosis
requires that the nurse
effectively cluster data that
irrefutably supports the
diagnosis.
HOW IS A DATA CLUSTER
FORMED?
 Developed when one piece of data signals
a potential problem
– It may be a positive or negative finding
 triggers analysis of inferences identified
– many closely related nursing diagnoses
come to mind
 leads to a collection of cues (units of
information)
– requires inclusion of major defining
characteristics
HOW DOES A STUDENT
NURSE IDENTIFY
INFERENCES?
 Abnormal units of data may indicate a
dysfunctional health pattern
 systematically review diagnosis
definitions and defining characteristics
that relates to the functional health
pattern
 determine if a data cluster exists to
support the diagnosis
What if you don’t have a
data cluster?
You can not use the diagnosis.
Additional assessment would
be required to ascertain the
client’s health status in relation
to the suspected dysfunction.
What if you do have a data
cluster?
Proceed in creating your
diagnostic statement using PES
format and add to priority list
What does your priority list
include?
 One part statements
– collaborative problems and syndromes
– make sure supporting data is recorded in first
column of NCP form
 2 part statements
– “risk for” statements
 3 part statements
– diagnostic label
– etiological factor
– supporting data
How do I rank my priority
sheet?
Consider possible frameworks
but remember to consider the
context of the client’s current
circumstances as it is recorded
in the daily nursing process
plan.
Organizing framework
Ask yourself how the diagnoses fit
according to the following
framework?
– Life-threatening concerns
– safety concerns
– patient concerns
– nursing concerns
Maslow’s framework
Basic/ Physical Needs
Safety Needs
Social Needs
Esteem Needs
Self Actualization
Assessment framework
LOC: level of consciousness
A:
airway
B:
breathing
C:
circulation/bleeding
I/O:
everything going in/out
wound:what does it look like?
Pain: present? Scale? Treatment?
safety: bed low? Call bell? Siderail?
Rank diagnoses in the
order of the highest priority
to the lowest.
Your nursing narrative is your
argument to support your
selections.
Place a number that
corresponds to its rank in front
of each diagnosis listed.
NCP#1 Assessment
SUBMIT TO YOUR CLINICAL INSTRUCTOR
– ASSESSMENT FORM
– DAILY NURSING PROCESS PLAN
– LAB DATA SHEET
– MEDICATION SHEET
– REFERENCE LIST
– PRIORITY NURSING DIAGNOSIS LIST
ENSURE THAT IS COMPREHENSIVE
AND COMPLETE.
Review your feedback on
your part one assessment to
integrate into your next
performance.
Successive performances are
measured to ensure that you
show progression in the
performance.
Selecting the appropriate
diagnoses
Review the contextual
circumstances of your client
and determine which of the
diagnostic plans would have
the greatest impact on the
client’s health status.
The care plan format
Demographic information
supporting data
collaborative problem/nursing
diagnosis
outcome
interventions
scientific rationale
evaluation
SUPPORTING DATA
THE ACTUAL DATA
– Subjective and objective that must be
present in your database; assessment
form, daily nursing process plan,
medication sheets, lab data,
diagnostics.
– Must be major and minor
manifestations relevant to the
diagnosis
NURSING DIAGNOSIS
Look at your priority list:
1 and 2 part statements
3 part statement
– Label
• NANDA label
– Etiology
• Physiologic, situational, treatment
related, environmental, maturational
– Evidencing data
Predicting outcomes
Nurses make statements about
what they would like to see the
client achieve to manage or
resolve the client’s response
that triggered the diagnostic
label.
OUTCOME CRITERIA
Outcomes are statements that include the
following:
– An action verb
• a measurable, observable behavior written in
terms of what the client will do/accomplish to
resolve or manage the human response
– a time frame
• a specific target date/time for achieving the
outcome that can realistically be accomplished
– May require more than one statement
Nurses design plans of care
to assist the client in
achieving outcomes.
Interventions are nursing
actions that directly and
indirectly influence client’s
health and environment
Characteristics of interventions
Specific actions performed by the
nurse the supports the client in:
– physiologic functioning
• simple and complex
– behavioral/psychosocial functioning
– protection against harm
– family unit functioning
– effective use of the health care system
ESSENTIAL COMPONENTS
OF INTERVENTIONS
– Must be linked to the outcome
– Are performance based
• What am I going to watch out for?
– EX: MONITOR OR ASSESS
• What am I going to do?
– EX: INSTRUCT, ASSIST, ENCOURAGE, SUCTION,
POSITION
• How does the medical plan impact the client’s
response and how can I integrate it?
– ADMINISTER, IRRIGATE, REGULATE, MAINTAIN
• Who else needs to be consulted?
– CONSULT MD, RESPIRATORY, DIETARY, PT
INTERVENTIONS
– LINK TO OUTCOMES
– MULTIPLE INTERVENTIONS MAY BE
REQUIRED TO ACHIEVE AN OUTCOME
– NEED TO DESCRIBE WHAT WILL BE
DONE, IN TERMS OF THE CLIENT, AND
CRITERIA FOR CONSULTATION
SCIENTIFIC RATIONALE
– This should be a succinct statement
that reflects the synthesis of your
understanding of the reasoning behind
the interventions inclusion into the
plan of care.
– Based on researching the references
cited.
EVALUATION
– Subjective And Objective Data That
Measures The Client’s Response To
The Plan
– No Such Thing As Pending Data
– Look At Your Outcome And
Interventions And Determine What
Data Reports The Client’s Response
Sample intervention/evaluation
 Monitor respiratory status, 
presence of adventitious
breath sounds, ineffective
cough,presence of
sputum; color
consistency, quantity.
 Administer humidified O2 
as ordered and mon pulse
oximetry
 position client HOB
elevated
 instruct client in C&DB
exercises
 encourage 2000 cc fluid/24
hours
respirations even and
unlabored, rate 18,
pulse oximetry 98% on
2 lpm humidified nasal
cannula. Lungs
bilateral rhonchi
occasional cough
productive for thin,
scant yellow sputum.
HOB elevated 45 deg,
Instructed to cough
and deep breath, states
understanding, return
demonstration given.
po fluids encouraged
tolerated 500cc.
CONCLUSION
Behavioral objectives for student
performance in nursing care plans
can be met through the
development of critical thinking
skills and dispositions that are
evident in every step of the nursing
process and the written record
known as nursing care plans.
CREATING AN
EXCELLENT NCP
Evidence adequate
inquiry, research and
use of best resources.
CREATING AN
EXCELLENT NCP
Deduce the most
accurate human
response (diagnostic
label) from the data
collected.
CREATING AN
EXCELLENT NCP
Analyze the human
responses and selects
the the diagnostic
labels that would have
the greatest impact on
the client’s outcome.
The student plans care for
the client that will:
Facilitate achievement of
outcomes,
Prescribe specific nursing
actions,
Use scientific reasoning based
on the latest literature.
The student will account
for the client’s response:
Through the organization of
subjective and objective data
that measures the client’s
response to the plan.