Learning Objectives
By the end of this section, you will be able to:
- Identify the purpose of the nursing process
- Define and apply the steps of the nursing process to patient care
- Explain how clinical judgment is used to guide patient care using the nursing process
The steps of the nursing process provide direction for nurses when making patient care decisions (Figure 4.2). Each decision affects the patient’s health status, and safe and effective decisions by nurses enhance patient outcomes (Nibbelink & Brewer, 2018). The thought process that allows nurses to arrive at a conclusion based on objective and subjective information about a patient—and thereby achieve positive patient outcomes—is called clinical judgment. This thought process is an essential part of safe and effective decision-making in nursing practice (Tanner, 2006). This chapter focuses on how to use clinical judgment when providing nursing care for medical-surgical patients.
The Nursing Process
The nursing process represents how nurses think. Nurses assess patients to discover subjective and objective patient data. The analysis of the data leads the nurse to diagnose a patient’s problems. It is important to note that nursing diagnoses differ from medical diagnoses: they are broader and holistic, encompassing aspects of physical health in addition to psychosocial, cultural, and environmental factors that affect the patient’s health. A nursing diagnosis is not the actual medical condition but rather the problems related to the medical condition. The diagnosis leads to the identification of patient outcomes (goals). The nurse begins to develop a plan of care based on prioritizing the identified problems and desired outcomes. The nurse then implements actions to treat the problems, prevent complications, and improve the patient’s overall health status. The patient’s condition is then evaluated by the nurse to determine if the actions brought about the expected patient outcomes and achieved care goals. The nursing process consists of five steps: assessment, diagnosis, planning, implementation, and evaluation (also known as ADPIE), each of which is discussed in more detail in the following sections.
Assessment
When providing nursing care, assessment includes gathering data from the patient, the patient’s medical record, the patient’s family members or caregivers, and physical assessment findings. Assessment also involves analyzing relevant data within the context of the patient’s current situation (Benner et al., 2009). This analysis enables the nurse to discover the essential data necessary for making patient care decisions. The nurse acknowledges the expected data, focuses on unexpected findings, and looks for patterns in the data to assist with the formation of a nursing diagnosis and an individualized plan of care. An example is when the nurse notices that over the past three cardiology clinic visits, there has been a gradual rise in the patient’s blood pressure measurements to above normal values. The blood pressure pattern is recognized as a trend and is not routine or expected in a healthy patient.
Diagnosis
The analysis of data provides direction for the nurse to identify or determine the patient’s current or potential problem(s) and develop a problem-based nursing diagnosis. The nurse also considers the patient’s specific situation. Continuing the example from the previous section, based on the assessment data, the patient receives a medical diagnosis of hypertension; some potential problem-based nursing diagnoses would be decreased cardiac output, risk for impaired cerebral tissue perfusion, and activity intolerance. Notice that the nursing diagnoses are broader and encompass problems the patient is experiencing; they do not simply name the condition with which the patient is diagnosed. During this step, the nurse also prioritizes the patient’s diagnosed problems. If the same patient arrived in the emergency department with a chief complaint of 10/10 chest pain, the patient’s potential myocardial infarction (heart attack) takes priority over treating the patient’s underlying hypertension. In this example, the context of the patient’s situation has changed. Prioritization of the established diagnoses is the foundation of the patient’s plan of care, which leads to the next step in the nursing process: planning.
Planning
For each diagnosis, the nurse identifies outcomes and goals that will enhance the patient’s condition and health status. For example, consider the patient with previously diagnosed hypertension who presents to the emergency department with 10/10 chest pain: the planned outcome is opening the blocked vessel to limit cardiac tissue damage. To achieve the intended outcome, the nurse observes and monitors for changes in objective data such as patient vital signs, cardiac rhythm, and physical symptoms such as chest pain and nausea, and reports abnormal findings to the provider. Everyone involved with the patient’s care is made aware of the planned actions to achieve the outcomes and provide optimal and targeted patient care.
Implementation
To achieve the prioritized outcomes, the nurse implements a series of planned actions, or nursing interventions. These actions are based on the planned patient outcomes. In the previous example, the actions are planned around the goal of preventing complications from the heart attack. The nursing actions are also prioritized to enhance patient safety and the effectiveness of the treatment and interventions.
Evaluation
Once the nursing interventions have been implemented, the nurse evaluates the patient’s current health status to determine if the actions were effective and if the patient outcomes were achieved. This evaluation may result in modifications of the diagnosis, plan, or nursing actions, and reflects the circular nature of the nursing process (see Figure 4.2). The nursing process continues to cycle as the plan of care is modified appropriately (American Nurses Association, 2021). For example, if a patient’s pain is not relieved by the prescribed pain medication, the nurse must return to the plan and modify it with additional interventions, such as advocating for a change in the medication order or providing nonpharmacological methods of pain control, such as position change, distraction, or application of ice.
Benefits of Using the Nursing Process in Practice
Using the nursing process has many benefits for nurses, patients, and other members of the health-care team. Using the nursing process
- promotes quality patient care;
- decreases omissions and duplications;
- provides a guide for all staff involved to provide consistent and responsive care;
- encourages collaborative management of a patient’s health-care problems;
- improves patient safety;
- improves patient satisfaction;
- identifies a patient’s goals and strategies to attain them;
- increases the likelihood of achieving positive patient outcomes;
- saves time, energy, and frustration by creating a care plan or path to follow; and
- improves continuity of care between various providers and institutions.
Clinical Judgment in Nursing
Historically, nursing was often viewed as a task-oriented career, meaning that nurses took orders from physicians without question and carried out nursing tasks. These tasks were usually simple, such as changing bed linens, helping patients use the toilet, and providing hygiene care. However, the profession of nursing has evolved into a more complex and autonomous career over the last several decades. As a valuable part of the health-care team, nurses now use critical thinking skills and clinical judgment in everyday practice to achieve positive patient outcomes. Many times, nurses are the ones tasked with making clinical decisions that will significantly affect the lives of their patients because they are often the first to notice changes and recognize potential problems. For example, a medical-surgical nurse notices that a patient develops facial droop and dysarthria and cannot move their arm. Based on these findings, the nurse decides to make the patient NPO (nil per us, which means “nothing by mouth”) as a safety precaution to prevent aspiration. The nurse will also perform a neurological assessment and notify the stroke emergency responders according to their institution’s policy.
In recent years, nursing education has also evolved to better train nurses to think critically and use clinical judgment in practice. The Clinical Judgment Measurement Model (CJMM) was developed by the National Council of State Boards of Nursing (NCSBN) to allow nurse educators to teach, assess, and measure the development of clinical judgment skills in nursing students and new graduates taking the National Council Licensure Examination (NCLEX-RN). The Next Generation NCLEX-RN (NGN) provides a better way to assess the clinical judgment and the decision-making abilities of nursing school graduates. This helps identify nurses who are prepared for contemporary practice, which requires nurses—even newly licensed ones—to make increasingly complex care decisions (National Council of State Boards of Nursing, 2024). The CJMM helps nursing students connect knowledge learned in the classroom to effective clinical care in practice. This model serves as the foundation for nursing critical thinking and skill development and is discussed in more detail throughout the rest of this chapter.