The nursing process provides a framework for independent nursing action, promotes a consistent structure for professional practice, and helps bring focus more precisely on each patient's health care needs. The nursing process is a systematic method for making decisions and implementing care. Steps in the nursing process include:
These phases of the nursing process—assessment, nursing diagnosis formation, outcome identification, care planning, implementation, and evaluation—are dynamic, flexible, and frequently overlap. The American Nurses Association (2015) has established these phases to meet professional Standards of Practice.
Becoming familiar with the nursing process has many benefits. It will allow you to apply your knowledge and skills in an organized, goal-oriented manner. It will also enable you to communicate about professional topics with colleagues from all clinical specialties and practice settings. Using the nursing process is essential to documenting nursing's role in the provision of comprehensive, quality patient care.
The recognition of the nursing process is an important development in the struggle for greater professional autonomy. By clearly defining those problems a nurse may treat independently, the nursing process has helped to dispel the notion that the nursing practice is based solely on carrying out the physician's orders.
Nursing remains in a state of professional evolution. Nurse researchers and expert practitioners continue to develop a body of knowledge specific to the field. Nursing literature is gradually providing direction to students and seasoned practitioners for evidence-based practice. A strong foundation in the nursing process will enable you to better assimilate emerging concepts and to incorporate these concepts into your practice. (See Table 1, Nursing's Approach to Problem Solving.)
| Dynamic and flexible, the phases of the nursing process resemble the steps that many other professions rely on to identify and correct problems. Here's how the nursing process phases correspond to the standard problem-solving method. | |
| NURSING PROCESS | PROBLEM-SOLVING METHOD |
| Assessment | |
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| Diagnosis | |
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| Outcome identification | |
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| Planning | |
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| Implementation | |
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| Evaluation | |
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The first and most critical phase in the nursing process—assessment—consists of the patient history, the physical examination, and pertinent diagnostic studies. Nurses also collect information about patient strengths and areas where potential problems exist. The other nursing process phases—nursing diagnosis formation, outcome identification, planning care, implementation, and evaluation—depend on the quality of the assessment data for their effectiveness.
A properly recorded initial assessment provides:
Your initial patient assessment begins with the collection of data (patient history, physical examination findings, and diagnostic study data) and ends with a statement of the patient's deficiency in, risk for, or readiness for enhancement of a specific problem that is written as the nursing diagnosis.
The information you collect when taking the patient's history, performing a physical examination, and analyzing test results serves as your assessment database. Your goal is to gather and record information that will be most helpful in assessing your patient. You can't realistically collect—or use—all the information that exists about the patient. To limit your database appropriately, ask yourself these questions:
Your answers will help you to be selective in collecting meaningful data during patient assessment.
The well-defined database for a patient may begin with admission signs and symptoms, chief complaint, or medical diagnosis. It may also center on the type of patient care given in a specific setting, such as the intensive care unit (ICU), the emergency department (ED), or an outpatient care center. For example, you wouldn't ask a trauma patient in the ED about a family history of breast cancer nor would you perform a routine breast examination. You would, however, do these types of assessment during a comprehensive health checkup in an outpatient care setting.
If you work in a setting where patients with similar diagnoses are treated, choose your database from information pertinent to this specific patient population. Even when addressing patients with similar diagnoses, complete a thorough assessment to make sure unanticipated problems don't go unnoticed.
The assessment data you collect and analyze fall into two important categories: subjective and objective. The patient's history, embodying a personal perspective of problems and strengths, provides subjective data. It's your most important assessment data source. Because it's also the most subjective source of patient information, it must be interpreted carefully.
In the physical examination of a patient—involving inspection, palpation, percussion, and auscultation (IPPA)—you collect objective data about the patient's health status or about the pathologic processes that may be related to illness or injury. In addition to adding to the patient's database, this information helps you interpret the patient's history more accurately by providing a basis for comparison. Use it to validate and amplify the historical data. However, don't allow the physical examination to assume undue importance—formulate your nursing diagnosis by considering all the elements of your assessment, not just the examination.
Laboratory test results are another objective form of assessment data and the third essential element in developing your assessment. Laboratory values will help you interpret—and usually clarify—your history and physical examination findings. The advanced technology used in laboratory tests enables you to assess anatomic, physiologic, and chemical processes that can't be assessed subjectively or by physical examination alone. For example, if the patient complains of fatigue (history) and you observe conjunctival pallor (physical examination), check the patient's hemoglobin level and hematocrit (laboratory data).
Both subjective (history) and objective (physical examination and laboratory test results) data are essential for comprehensive patient assessment. They validate each other and together provide more data than either can provide alone. By considering history, physical examination, and laboratory data in their appropriate relationships to one another, you'll be able to develop a nursing diagnosis on which to formulate an effective care plan.
This portion of the assessment consists of the subjective data you collect from the patient. A complete health history provides the following information about a patient:
Follow this orderly format in taking the patient's history, but allow for modifications based on the patient's chief complaint or concern. For example, the health history of a patient with a localized allergic reaction will be much shorter than that of a patient who complains vaguely of mental confusion and severe headaches.
If the patient has a chief complaint, use information from the health history to decide whether problems stem from physiologic causes or psychophysiologic maladaptation and how nursing interventions may help. The depth of such a history depends on the patient's cooperation and your skill in asking insightful questions.
A patient may request a complete physical checkup as part of a periodic (perhaps annual) health maintenance routine. Such a patient may not have a chief complaint. Therefore, this patient's health history should be comprehensive with detailed information about lifestyle, self-image, family and other interpersonal relationships, and degree of satisfaction with current health status.
Be sure to record health history data in an organized fashion to ensure the information will be meaningful to everyone involved in the patient's care. Some health care facilities provide patient questionnaires or computerized checklists. (See Box 1, Using an Assessment Checklist.)
Box 1.Using an Assessment Checklist
Use an assessment checklist such as this to ensure that you cover all key points during your health history interview. Although the format may vary from one facility to another, all assessment checklist guides include the same key elements.
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These forms make history-taking easier, but they aren't always available. Therefore, you must know how to take a comprehensive health history without them. This is easy to do if you develop an orderly and systematic method of interviewing. Ask the history questions in the same order every time. With experience, you'll know which types of questions to ask in specific patient situations.
When interviewing the patient, use this review of systems as a guide.
When documenting the health history, be sure to record both negative and positive findings, that is, note the absence of symptoms that other history data indicate might be present. For example, if a patient reports abdominal pain and burning, ask about experiencing nausea and vomiting or noticing blood in stools. Record the presence or absence of these symptoms.
Remember that the information you record will be used by others who will be caring for the patient. Recorded information can be used as a legal document in a liability case, a malpractice suit, or an insurance disability claim. With these considerations in mind, record history data thoroughly and precisely. Continue your questioning until you're satisfied that you've recorded sufficient detail. Don't be satisfied with inadequate answers, such as “a lot” or “a little”; such subjective terms must be explained within the patient's context to be meaningful. If taking notes seems to make the patient anxious, explain the importance of keeping a written record. To facilitate accurate recording of the patient's answers, familiarize yourself with standard history data abbreviations.
When you complete the patient's health history, it becomes part of the permanent written record. It will serve as a subjective database with which you and other health care professionals can monitor the patient's progress. Remember that history data must be specific and precise. Avoid generalities. Instead, provide pertinent, concise, detailed information that will help determine the direction and sequence of the physical examination—the next phase in your patient assessment.
After taking the patient's health history, the next step in the assessment process is the physical examination. During this assessment phase, you obtain objective data that usually confirm or rule out suspicions raised during the health history interview.
Use four basic techniques to perform a physical examination: inspection, palpation, percussion, and auscultation. These skills require you to use your senses of sight, hearing, touch, and smell to formulate an accurate appraisal of the structures and functions of body systems. Using IPPA skills effectively lessens the chances that you'll overlook something important during the physical examination. In addition, each examination technique collects data that validate and amplify data collected through other IPPA techniques.
Accurate and complete physical assessments depend on two interrelated elements. One is the critical act of sensory perception, by which you receive and perceive external stimuli. The other element is the conceptual, or cognitive, process by which you relate these stimuli to your knowledge base. This two-step process gives meaning to your assessment data.
Develop a system for assessing patients that identifies problem areas in priority order. By performing physical assessments systematically and efficiently instead of in a random or indiscriminate manner, you'll save time and identify priority problems quickly. First, choose an examination method. The most commonly used methods for completing a total systematic physical assessment are head-to-toe and major body systems.
The head-to-toe method is performed by systematically assessing the patient by—as the name suggests—beginning at the head and working toward the toes. Examine all parts of one body region before progressing to the next region to save time and to avoid tiring the patient or yourself. Proceed from left to right within each region so you can make symmetrical comparisons, that is, when examining the head, proceed from the left side of the head to the right side. After completing both sides of one body region, proceed to the next.
The major body systems method of examination involves systematically assessing the patient by examining each body system in priority order or in an established sequence.
Both the head-to-toe and the major body systems methods are systematic and provide a logical, organized framework for collecting physical assessment data. They also provide the same information; therefore, neither is more correct than the other. Choose the method (or a variation of it) that works well for you and is appropriate for your patient population. Follow this routine whenever you assess a patient, and try not to deviate from it.
To decide which method to use, first determine whether the patient's condition is life-threatening. Identifying the priority problems of a patient suffering from a life-threatening illness or injury—for example, severe trauma, a heart attack, or gastrointestinal hemorrhage—is essential to preserve the patient's life and function and prevent additional damage.
Next, identify the patient population to which the patient belongs and take the common characteristics of that population into account in choosing an examination method. For example, elderly or debilitated patients tire easily; for these patients, you should select a method that requires minimal position changes. You may also defer parts of the examination to avoid tiring the patient.
Try to view the patient as an integrated whole rather than as a collection of parts, regardless of the examination method you use. Remember, the integrity of a body region may reflect adequate functioning of many body systems, both inside and outside the region in question. For example, the integrity of the chest region may provide important clues about the functioning of the cardiovascular and respiratory systems. Similarly, the integrity of a body system may reflect adequate functioning of many body regions and of the various systems within these regions.
You may want to plan your physical examination around the patient's chief complaint or concern. To do this, begin by examining the body system or region that corresponds to the chief complaint. This allows you to identify priority problems promptly and reassures the patient that you're paying attention to his or her chief complaint.
Physical examination findings are crucial to arriving at a nursing diagnosis and ultimately to developing a sound nursing care plan. Record your examination results thoroughly, accurately, and clearly. Although some examiners don't like to use a printed form to record physical assessment findings, preferring to work with a blank paper, others believe that standardized data collection forms can make recording physical examination results easier. These forms simplify comprehensive data collection and documentation by providing a concise format for outlining and recording pertinent information. They also remind you to include all essential assessment data.
When documenting, describe exactly what you've inspected, palpated, percussed, or auscultated. Don't use general terms, such as normal, abnormal, good, or poor. Instead, be specific. Include positive and negative findings. Try to document as soon as possible after completing your assessment. Remember that abbreviations aid conciseness. (See Box 2, Documentation Tips.)
Remember these rules about documenting your initial assessment:
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According to NANDA International, the nursing diagnosis is a “clinical judgment concerning a human response to health conditions/life processes, or a susceptibility to that response, that is recognized in an individual, family, community” (Herdman et al., 2024, p. 30). The nursing diagnosis must be supported by clinical information obtained during patient assessment. (See Box 3, Nursing Diagnoses and the Nursing Process.)
Box 3.Nursing Diagnoses and the Nursing Process
When first described, the nursing process included only assessment, planning, implementation, and evaluation. However, during the past three decades, several important events have helped to establish diagnosis as a distinct part of the nursing process.
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Each nursing diagnosis describes a patient problem that a nurse can legally manage. Becoming familiar with nursing diagnoses will enable you to better understand how nursing practice is distinct from medical practice. Although the identification of problems commonly overlaps in nursing and medicine, the approach to treatment clearly differs. Medicine focuses on curing disease; nursing focuses on holistic care that includes care and comfort. Nurses can independently diagnose and treat the patient's response to illness, certain health problems and risk for health problems, readiness to improve health behaviors, and the need to learn new health information. Nurses comfort, counsel, and care for patients and their families until they're physically, emotionally, and spiritually ready to provide self-care.
The nursing diagnosis expresses your professional judgment of the patient's clinical status, responses to treatment, and nursing care needs. In effect, the nursing diagnosis defines the practice of nursing. Translating the patient's history, physical examination, and laboratory data into a nursing diagnosis involves organizing the data into clusters and interpreting what the clusters reveal about the patient's ability to meet basic needs. In addition to identifying the patient's needs in coping with the effects of illness, consider what assistance the patient requires to grow and develop to the fullest extent possible.
Your nursing diagnosis describes the cluster of signs and symptoms indicating an actual or potential health problem that you can identify—and that your care can resolve. Nursing diagnoses that indicate potential health problems can be identified by the words “risk for,” which appear in the diagnostic label. There are also nursing diagnoses that focus on prevention of health problems and enhanced wellness.
Creating your nursing diagnosis is a logical extension of collecting assessment data. In your patient assessment, you asked each history question, performed each physical examination technique, and considered each laboratory test result because it provided evidence of how the patient could be helped by your care or because the data could affect nursing care.
To develop the nursing diagnosis, use the assessment data you've collected to develop a problem list. Less formal in structure than a fully developed nursing diagnosis, this list describes the patient's problems or needs. It's easy to generate such a list if you use a conceptual model or an accepted set of criterion norms. Examples of such norms include normal physical and psychological development and Gordon's functional health patterns.
You can identify the patient's problems and needs with simple phrases, such as poor circulation, high fever, or poor hydration. Next, prioritize the problems on the list and then develop the working nursing diagnosis.
Some nurses are confused about how to document a nursing diagnosis because they think the language is too complex. However, by remembering the following basic guidelines, you can ensure that your diagnostic statement is correct:
Whenever possible, use the terminology recommended by NANDA-I.
NANDA-I diagnostic headings, when combined with suspected etiology and supported by defining characteristics or risk factors (Herdman et al., 2024), provide a clear picture of the patient's needs. Thus, for clarity in charting, start with one of the NANDA-I categories as a heading for the diagnostic statement. The category can reflect an actual or potential problem. Consider this sample diagnosis:
One major pitfall in developing a nursing diagnosis is writing one that nursing interventions can't treat. Errors can also occur when nurses take shortcuts in the nursing process, either by omitting or hurrying through assessment or by basing the diagnosis on inaccurate assessment data.
Keep in mind that a nursing diagnosis is a statement of a health problem that a nurse is licensed to treat—a problem for which you'll assume responsibility for therapeutic decisions and accountability for the outcomes. A nursing diagnosis is not a
At first, these distinctions may not be clear. The following examples should help clarify what a nursing diagnosis is:
You assess your patient to obtain data in order to make a nursing diagnosis, just as the physician examines a patient to establish a medical diagnosis. It is important to understand the differences between the two and remember that they sometimes overlap. You perform a complete assessment to identify patient problems that nursing interventions can help resolve; your nursing diagnoses state these problems. (Some problems may be secondary to medical treatment.) If you plan your care of a patient around only the medical aspects of an illness, you'll probably overlook significant problems.
For example, suppose the patient's medical diagnosis is a fractured femur. In your assessment, take a careful history. Include questions to determine whether the patient has adequate financial resources to cope with prolonged disability. To assess the patient's capacity to adjust to the physical restrictions caused by the disability, gather data about his or her previous lifestyle.
Suppose your physical examination of this patient—in addition to uncovering signs and symptoms pertaining to the medical diagnosis—reveals actual or potential skin breakdown secondary to immobility. Your nursing diagnoses, in that case, may include home maintenance management impairment, diversional activity deficit (related to prolonged immobility), and risk for skin integrity impairment.
The care plan you prepare for this patient should include the nursing interventions suggested by your nursing diagnoses as well as the nursing actions necessary to fulfill the patient's medical treatment plan. When integrated into a care plan, the nursing and medical diagnoses describe the complete nursing care the patient needs. See Box 4, Examples of Medical and Nursing Diagnoses, for examples of differences between medical and nursing diagnoses.
Box 4.Examples of Medical and Nursing Diagnoses
Study the following examples here to better understand the difference between medical and nursing diagnoses:
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During this phase of the nursing process, you will identify expected outcomes for the patient. Derived from the patient's nursing diagnoses, expected outcomes are goals that are measurable, patient focused, realistic, clear, concise, and time limited. These goals may be short- or long term. Short-term goals include those of immediate concern that can be achieved quickly. Long-term goals take more time to achieve and usually involve prevention, patient teaching, and rehabilitation.
In many cases, you can identify expected outcomes by converting the nursing diagnosis into a positive statement. For instance, for the nursing diagnosis “impaired physical mobility related to a fracture of the right hip,” the expected outcome might be “The patient will ambulate independently before discharge.”
When writing the care plan, state expected outcomes in terms of the patient's behavior—for example, “the patient correctly demonstrates turning, coughing, and deep breathing.” Also, identify a target time or date by which the expected outcomes should be accomplished. The expected outcomes will serve as the basis for evaluating your nursing interventions.
If possible, consult with the patient and the patient's family when establishing expected outcomes. As the patient progresses, expected outcomes should be increasingly directed toward planning for discharge and follow-up care.
Outcome statements should be tailored to your practice setting. For example, in the ICU, you may focus on maintaining hemodynamic stability, whereas in a rehabilitation unit, you would focus on maximizing the patient's independence and preventing complications. (See Box 5, Understanding NOC.)
The Nursing Outcomes Classification (NOC) is a standardized language of patient or client outcomes that was developed by a nursing research team at the University of Iowa. It contains 540 outcomes organized into 34 classes and 7 domains. Each outcome has a definition, list of measurable indicators, and references. The outcomes are research based, and studies are ongoing to evaluate their reliability, validity, and sensitivity. More information about NOC can be found at the Center for Nursing Classification and Clinical Effectiveness (https://nursing.uiowa.edu/cncce/nursing-outcomes-classification-overview). |
Expected outcomes must be stated in measurable terms. Measurable terms describe observable results and provide the criteria for success; they clearly describe the expected result after interventions are implemented. Avoid ambiguous language such as better, improve, or decrease because such terms are difficult to quantify. When writing expected outcomes in your care plan, always start with a specific action verb that focuses on the patient's behavior. By telling your reader how the patient should look, walk, eat, drink, turn, cough, speak, or stand, for example, you give a clear picture of how to evaluate progress.
Avoid starting expected outcome statements with allow, let, enable, or similar verbs. Such words focus attention on your own and other health care team members' behavior—not on the patient's.
With many documentation formats, you won't need to include the phrase “The patient will …” with each expected outcome statement. You will, however, have to specify which person the goals refer to when family, friends, or others are directly concerned.
Make sure target dates are realistic. Be flexible enough to adjust the date if the patient needs more time to respond to your interventions.
The nursing care plan refers to a written plan of action designed to help you deliver quality patient care. It includes relevant nursing diagnoses, expected outcomes, and nursing interventions. Keep in mind that the care plan usually forms a permanent part of the patient's health record and will be used by other members of the nursing team. The care plan may be integrated into an interdisciplinary plan for the patient. In this instance, clear guidelines should outline the role of each member of the health care team in providing care.
To provide quality care for each patient, you must plan and direct that care. Writing a care plan allows you to document the scientific method used throughout the nursing process. In the care plan, you summarize the patient's problems and needs (as nursing diagnoses) and identify appropriate nursing interventions and expected outcomes. A care plan that's well conceived and properly written helps decrease the risk of incomplete or incorrect care by
Formulating the care plan involves three stages:
The planning phase culminates when you write the care plan and document the nursing diagnoses, expected outcomes, nursing interventions, and evaluations for expected outcomes. Write your care plan in concise, specific terms so that other health care team members can follow it. Keep in mind that because the patient's problems and needs will change, you'll have to review your care plan frequently and modify it when necessary.
Care planning formats vary from one health care facility to another. For example, you may write your care plan on a form supplied by the hospital or you can use software that's approved by your facility. Nearly all care planning formats include space in which to document the nursing diagnoses, expected outcomes, and nursing interventions. In many health care facilities, you may also document assessment data and discharge planning on the care plan.
No matter which format you use, be sure to sign and date the care plan, even though you may have to make revisions if your nursing interventions don't work. Remember—the patient's care plan becomes part of the permanent record and shouldn't be erased or destroyed. The information must remain intact, enabling you and other health care team members to readily refer to nursing interventions used in the past. (See Box 6, Guidelines for Writing a Care Plan.)
Box 6.Guidelines for Writing a Care Plan
Keeping these tips in mind will help you write an accurate and useful care plan.
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Be specific when writing your care plan. By discussing specific problems, expected outcomes, nursing interventions, and evaluations for expected outcomes, you leave no doubt as to what needs to be done by other health care team members. For example, when listing nursing interventions, be sure to include when the action should be implemented, who should be involved in each aspect of implementation, and the frequency, quantity, and method to be used. Specify dates and times when appropriate. List target dates for each expected outcome.
If your nursing interventions have resolved the problem on which you've based the nursing diagnosis, write “discontinued” next to the diagnostic statement on the care plan and list the date you discontinued the interventions. If your nursing interventions haven't resolved the problem by the target date, reevaluate your plan and do one of the following:
You'll need to update and modify a patient's care plan as problems (or priorities) change and resolve, new assessment information becomes available, and you evaluate the patient's responses to nursing interventions.
During this phase, you put your care plan into action. Implementation encompasses all nursing interventions directed toward solving the patient's nursing problems and meeting health care needs. While you coordinate implementation, you also seek help from other caregivers, the patient, and the patient's family. (See Box 7, Understanding NIC.)
The Nursing Interventions Classification (NIC) is a research-based clinical tool that standardizes and defines the knowledge base for nursing practice; it was developed by a nursing research team at the University of Iowa. It contains 565 interventions organized into 30 classes and 7 domains. Each intervention has a definition, list of indicators, publication facts line, and references (Butcher et al., 2018). The interventions are research based, and studies are ongoing to evaluate the effectiveness and cost of nursing treatments. More information about NIC can be found at the Center for Nursing Classification and Clinical Effectiveness (https://nursing.uiowa.edu/cncce/nursing-interventions-classification-overview). |
Implementation requires some (or all) of the following interventions:
Incorporate these elements into the implementation stage:
Implementation isn't complete until you've documented each intervention, the time it occurred, the patient's response, and any other pertinent information. Make sure each entry relates to a nursing diagnosis. Remember that any action not documented may be overlooked during quality assurance monitoring or evaluation of care. Thorough documentation offers a way for you to take rightful credit for your contribution in helping a patient achieve the highest possible level of wellness. After all, nurses use a unique and worthwhile combination of interpersonal, intellectual, and technical skills when providing care. (See Box 8, Nursing Interventions: Three Types.)
Box 8.Nursing Interventions: Three Types
Knowing the three types of nursing interventions will help you document implementation appropriately.
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In this phase of the nursing process, you assess the effectiveness of the care plan by answering such questions as:
Evaluation also helps you determine whether the patient received high-quality care from the nursing staff and the health care facility.
Include the patient, family members, and other health care professionals in the evaluation. Then follow these steps:
When evaluating and documenting the patient's care, collect information from all available sources—for example, the patient's medical record, family members, other caregivers, and the patient. Include your own observations.
During the evaluation process, ask yourself these questions:
In a growing number of health care settings—inpatient and outpatient, acute and long-term care—critical pathways are being used to guide the process of care for a patient. Critical pathways describe the course of a specific health-related condition. A critical pathway may be used along with or instead of a nursing care plan, depending on the standards set by the individual health care facility. These tools may also be referred to as clinical pathways, care maps, collaborative care plans, or multidisciplinary action plans. (See Box 9, Developing a Critical Pathway.)
Box 9.Developing a Critical Pathway
The critical pathway is an interdisciplinary tool that requires the collaborative efforts of all disciplines involved in patient care. The interdisciplinary team must decide on a diagnosis, select a set of achievable outcomes, and agree on a plausible time line for achieving the desired outcomes. Note that when establishing standard practices for treatment of a given condition, it has usually proved difficult for physicians to achieve consensus. |
The concept of the critical pathway evolved out of the growth of managed care and the development of the case management model in the early 1990s. Pressure from managed care organizations to control costs led to the evolution of case management.
In case management, one professional—usually a nurse or a social worker—assumes responsibility for coordinating care so that patients move through the health care system in the shortest time and at the lowest cost possible.
Early on, case managers used the nursing process and based their plans on nursing diagnoses. Over time, however, it became evident that a multidisciplinary approach was needed to adequately monitor the length of stay and reduce overall costs. This led to the development of the critical pathway concept.
In critical pathways, a time line is defined for each condition and for the achievement of expected outcomes. By reading the critical pathway, caregivers can determine on any given day where the patient should be in his or her progress toward optimal health.
The critical pathway provides a method for physicians and nurses to standardize and organize care for routine conditions. These pathways also make it easier for case managers to track data needed to
The most successful critical pathways have been developed for medical diagnoses with predictable outcomes, such as hip replacement, mastectomy, myocardial infarction, and cardiac catheterization. Critical pathways work best with high-volume, high-risk, high-cost conditions or procedures for which there are predictable outcomes.
Developing a care plan helps the nursing student improve problem-solving technique, learn the nursing process, improve written and verbal communication, and develop organizational skills. More important, it shows how to apply classroom and textbook knowledge to practice.
Because the purpose is to teach the care planning process, the student care plan is longer than the standard plan used in most health care facilities. In a step-by-step manner, student care plans progress from assessment to evaluation. However, some teaching institutions model the student care plan on the plan used by the affiliated health care institution, adding a space for the scientific rationale for each nursing intervention selected.
Writing out all of your planned actions enables you to review planned nursing activities with your clinical instructor. This is an opportunity to consider whether you have complete assessment data to support your diagnoses and interventions and whether you've taken into consideration all the problems that a more experienced nurse is likely to identify. See Box 10, Care Plans, for an explanation of each section of a care plan.
All care plans contain the following sections:
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Using a critical pathway can be helpful, especially for nursing students and new graduates. You may be assigned to provide care to a particular patient for only 1 or 2 days. Seeing the entire pathway and examining the outcomes the patient is expected to achieve will help you obtain a broader clinical perspective on care.
Using a critical pathway as a guide for delivering care does not negate the need to formulate and utilize nursing diagnoses. Nursing diagnoses continue to define the primary responsibility of nursing—to diagnose and treat human responses to actual or potential health problems. The full nursing care needs of any patient are unlikely to be documented in a critical pathway. When using a pathway, always keep in mind that the patient may require nursing intervention beyond what's specified in the critical pathway.
For example, a patient enters a hospital for a hip replacement and can't communicate verbally because of a recent stroke. The critical pathway wouldn't include measures to assist the patient to disclose personal needs. Therefore, you would develop a nursing care plan around the diagnosis, “Impaired verbal communication related to decreased circulation to the brain.”
Even if you practice in a clinical setting that relies on critical pathways to fill documentation requirements, the Nursing Diagnosis Reference Manual, 12th edition, will prove to be a valuable resource for identifying and treating each patient's unique nursing needs. Creating a care plan based on carefully selected nursing diagnoses and using it along with a critical pathway will enable you to provide your patients with high-quality collaborative care that includes a strong nursing component.