Nursing Foundations · Nursing Process

Nursing Process

Critical Thinking in Nursingdefinition

The Kataoka-Yahiro and Saylor model defines three levels of critical thinking: basic, complex, and commitment.

in simple words: A nurse's reasoning grows from rule-following to independent accountability.

Three Levels

Basic – Follows rules and procedures without question. Notes a deviation but waits for the doctor to interpret it.
Complex – Analyses the patient's condition, identifies a deviation from expected recovery, and understands that remedial actions are necessary. Collaborates with the doctor but independently concludes that a problem exists.
Commitment – Higher autonomy; independently decides on and takes accountability for the action without needing to consult others first.

Nursing Process · Nursing Foundations

Critical Thinking Skills

Self-regulationdefinition

The core critical thinking skill of monitoring one's own reasoning and correcting errors in interpretation, analysis, inference, evaluation or explanation.

in simple words: The metacognitive 'quality control' step of critical thinking.

e.g. Used in reflective practice to link actions with outcomes and improve clinical judgment.

Other cognitive skills

Analysis – breaking down information to understand its components and relationships.
Interpretation – clarifying the meaning of data or events.
Explanation – articulating and justifying one's reasoning and conclusions to others.

Nursing Process · Nursing Foundations

Nursing Process Steps

Nursing Processdefinition

A systematic problem-solving method used to plan, organize, and deliver individualized patient care.

in simple words: The structured framework for clinical decision-making and action.

Five Steps (ADPIE)

AssessmentSystematic, continuous collection, validation, and communication of patient data.
DiagnosisAnalyzing and interpreting data to identify actual or potential health problems.
PlanningSets priorities, patient-centered goals, and nursing interventions.
ImplementationPerforms the interventions specified in the care plan.
EvaluationDetermines whether the patient met planned goals and measures intervention effectiveness.

Nursing Process · Nursing Foundations

Assessment & Data

Nursing Assessmentdefinition

The first step of the nursing process; the systematic, continuous collection, validation, and communication of patient data.

in simple words: The foundation for all later steps.

Types of Data

Subjective – What the patient says (symptoms such as pain or dizziness).
Objective – What the nurse observes or measures (signs such as blood pressure or rash).

Holistic Assessment

Covers physical, psychological, emotional, socio-cultural, and spiritual aspects. A complete database allows individualized care planning.

Nursing Process · Nursing Foundations

Nursing Diagnosis

Nursing Diagnosisdefinition

A clinical judgment about a patient's response to a health condition or life process.

in simple words: Focuses on the person and their functional and emotional responses, not on the disease itself.

PES Format

P – Problem (NANDA-I diagnostic label)
E – Etiology (cause or contributing factor)
S – Signs/Symptoms (defining characteristics)

Linking Phrases

Use "related to" to link the problem to its etiology. Use "as manifested by" or "evidenced by" to introduce the defining characteristics (signs and symptoms).

Nursing Process · Nursing Foundations

Diagnosis vs Medical

Nursing vs Medical Diagnosis

Feature	Nursing Diagnosis	Medical Diagnosis
Focus	Patient's response to disease	Disease itself
Example	Risk for Unstable Blood Glucose Level	Diabetes Mellitus
Purpose	Basis for selecting nursing interventions	Identifies and names the disease
Accountability	Nurse is accountable	Doctor is accountable

Nursing Process · Nursing Foundations

Planning & Outcomes

Planningdefinition

The third nursing process stage; it sets priorities, patient-centered goals, and nursing interventions after assessment and nursing diagnosis.

in simple words: Deciding what to do and how to do it.

Key Activities

Setting priorities – Based on the client's condition using ABC and Maslow's hierarchy.
Identifying goals – Patient-centered, measurable expected outcomes with a time frame.
Selecting interventions – Evidence-based nursing actions.

Expected Outcomedefinition

A specific, measurable statement of patient behaviour or physiological response with a defined time frame, used to evaluate nursing interventions.

in simple words: Follows SMART criteria: Specific, Measurable, Attainable, Realistic, Timed.

Nursing Process · Nursing Foundations

Implementation

Implementationdefinition

The fourth nursing process stage, in which the nurse performs the interventions specified in the care plan.

in simple words: The 'doing' phase, where the care plan is carried out and documented.

Types of Interventions

Independent – Nurse-initiated, requiring no doctor's order (e.g., positioning to prevent pressure ulcers).
Dependent – Physician-initiated; requires a doctor's order.
Collaborative – Requires combined expertise of more than one discipline (e.g., doctor, nurse, dietitian).

Nursing Process · Nursing Foundations

Evaluation & Audit

Evaluationdefinition

The final nursing process stage; it determines whether the patient met planned goals and measures intervention effectiveness.

in simple words: Compares actual outcomes with desired outcomes to decide whether to continue, modify, or discontinue the plan.

Audit Types

Nursing audit – Systematic, formal, written appraisal of the quality of clinical nursing care against established criteria and standards. Often retrospective.
Concurrent nursing audit – Assesses care during its delivery, allowing immediate corrections.
Medical audit – Evaluates the quality and appropriateness of medical care provided by doctors, not nursing care.