NUR 2115 Exam 2 Study Guide
Module 4 – Clinical Judgement and Nursing Process
➢ The nursing process consists of 5 steps.
1. Assessment if the first step. Data is collected during this step so that the rest of the nursing
process may be efficiently carried out.
• Nursing assessments focus on the patient’s responses to health problems, not the data
based from the patient’s diagnosis.
• Initial Assessment – preformed by the nurse shortly after the patient is admitted to a
facility. This assessment typically follows the guidelines set by the standards of the
facility and establishes a baseline database for the patient. Allows the nurse to gather
health data and identify health problems to set priorities for further focused
assessments.
• Focused Assessment – Nurse gathers data about a problem that has already been
identified.
✓ What are your signs and symptoms?
✓ When did they first start?
✓ What makes it better/worse?
• Emergency Assessment – Done when a psychological or physiological crisis occurs to
identify what life-threatening problems are occurring.
• Time-Lapsed Assessment - This is a scheduled assessment to compare a patient’s current
condition with their baseline condition. Most residents in long-term health care have
time-lapsed assessments scheduled periodically.
• Priorities to set during assessment include health orientation, developmental stage,
culture and the patients need for nursing.
• Always validate assessment data before using it for diagnosing.
2. Diagnosis is the second step. Data gathered from the assessment are utilized to form a
judgement about the patients’ health. The purposes of diagnosing are:
✓ Identify how a person, group, community, responds to an actual or potential
health and life process.
✓ Identify the factors that contribute to or cause the health problems.
✓ Identify resources and strengths that that person or community can draw on to
help resolve or prevent the problem.
• During the diagnosing step of the nursing process the nurse clarifies the exact nature of
the patient’s problems and risks that must be addressed to achieve the patient’s
outcome of care. Conclusions made during this step affects selected interventions and
the entire plan of care.
• NANDA – North American Nursing Diagnosis Association.
✓ “Nursing diagnosis is a clinical judgement about personal, family or community
responses to actual or potential health problems/life processes. Nursing
diagnosis provides the basis of selecting nursing interventions to achieve
outcomes for which the nurse is accountable.”
• Nursing diagnoses are written to describe patient problems that the nurse can treat
independently.
, • Collaborative problems are the nurse’s primary responsibility and are managed using
physician -prescribed and nurse interventions to minimize the complications of the even.
Unlike nursing diagnoses the prescription for treatment comes from nursing, medicine
and other disciplines. Collaborative problems include diagnosis documented by the
nurse that may require intervention of other medical professionals.
✓ PC: Potential pneumonia related to impaired physical mobility.
• Actual nursing diagnosis – Diagnosis that represents problems that have already been
validated. These types of diagnosis include a label, definition, defining characteristics
and related factor.
• Risk diagnosis – Clinical judgements that a person, family or community is more
vulnerable to developing a problem than others.
• Possible nursing diagnosis – A suspected problem needing more data utilized to confirm
or rule out the diagnosis.
• Wellness diagnosis – Clinical judgements that state that a person, family, or community
is ready to advance from one level of health to another. Two components that must be
present are a desire for a higher level of wellness and an effective present status or
function.
✓ Readiness for enhanced…. (family coping, health maintenance, self-esteem, ect.)
• Syndrome nursing diagnosis – Compromised of a cluster of actual or risk nursing
diagnosis predicted to be present because of a specific situation or certain event. (PTSD)
3. Planning is the third step, during planning the nurse identifies outcomes and formulates goals
for the patient, family or community. Outcomes should be specific, measurable, attainable,
reasonable and time-specific. (S.M.A.R.T)
• Informal planning may occur at any time such as an emergency or simply when a nursing
is thinking about how they could better help their patient. Informal planning if formal
planning without documentation.
• Outcome identification and planning allows the nurse to set priorities, identify expected
patient outcomes, select necessary interventions to achieve these outcomes and
communicate the plan of care among the patient, family and other staff involved in the
patients care.
• Initial planning – preformed by the nurse along with the initial assessment. A
comprehensive plan that addresses each problem listed in the prioritized nursing
diagnoses and identifies appropriate patient goals and the related nursing care.
• Ongoing planning – This planning is completed each time the nurse interacts with the
patient. Data is collected to ensure the plan or care is kept up to date to resolve
identified health problems, manage risk factors and promote function. During ongoing
planning nursing diagnosis may be clarified or modified and new planning may be
implemented.
• Discharge planning – Ensures that the patient and family outcomes and needs are met as
the patient moves from a care setting to home, or from on care setting to another.
Education about continuity of care at home or in another health care setting is provided
by the nurse upon discharge.
• Care planning may include standardized templates set on the EHR, concept mapping,
ISBARR during patient hand-off, and clinical pathways.
4. Intervention/Implementation is the fourth step in which the nurse carries out actions that were
set for the patient in the planning step of the nursing process.
Module 4 – Clinical Judgement and Nursing Process
➢ The nursing process consists of 5 steps.
1. Assessment if the first step. Data is collected during this step so that the rest of the nursing
process may be efficiently carried out.
• Nursing assessments focus on the patient’s responses to health problems, not the data
based from the patient’s diagnosis.
• Initial Assessment – preformed by the nurse shortly after the patient is admitted to a
facility. This assessment typically follows the guidelines set by the standards of the
facility and establishes a baseline database for the patient. Allows the nurse to gather
health data and identify health problems to set priorities for further focused
assessments.
• Focused Assessment – Nurse gathers data about a problem that has already been
identified.
✓ What are your signs and symptoms?
✓ When did they first start?
✓ What makes it better/worse?
• Emergency Assessment – Done when a psychological or physiological crisis occurs to
identify what life-threatening problems are occurring.
• Time-Lapsed Assessment - This is a scheduled assessment to compare a patient’s current
condition with their baseline condition. Most residents in long-term health care have
time-lapsed assessments scheduled periodically.
• Priorities to set during assessment include health orientation, developmental stage,
culture and the patients need for nursing.
• Always validate assessment data before using it for diagnosing.
2. Diagnosis is the second step. Data gathered from the assessment are utilized to form a
judgement about the patients’ health. The purposes of diagnosing are:
✓ Identify how a person, group, community, responds to an actual or potential
health and life process.
✓ Identify the factors that contribute to or cause the health problems.
✓ Identify resources and strengths that that person or community can draw on to
help resolve or prevent the problem.
• During the diagnosing step of the nursing process the nurse clarifies the exact nature of
the patient’s problems and risks that must be addressed to achieve the patient’s
outcome of care. Conclusions made during this step affects selected interventions and
the entire plan of care.
• NANDA – North American Nursing Diagnosis Association.
✓ “Nursing diagnosis is a clinical judgement about personal, family or community
responses to actual or potential health problems/life processes. Nursing
diagnosis provides the basis of selecting nursing interventions to achieve
outcomes for which the nurse is accountable.”
• Nursing diagnoses are written to describe patient problems that the nurse can treat
independently.
, • Collaborative problems are the nurse’s primary responsibility and are managed using
physician -prescribed and nurse interventions to minimize the complications of the even.
Unlike nursing diagnoses the prescription for treatment comes from nursing, medicine
and other disciplines. Collaborative problems include diagnosis documented by the
nurse that may require intervention of other medical professionals.
✓ PC: Potential pneumonia related to impaired physical mobility.
• Actual nursing diagnosis – Diagnosis that represents problems that have already been
validated. These types of diagnosis include a label, definition, defining characteristics
and related factor.
• Risk diagnosis – Clinical judgements that a person, family or community is more
vulnerable to developing a problem than others.
• Possible nursing diagnosis – A suspected problem needing more data utilized to confirm
or rule out the diagnosis.
• Wellness diagnosis – Clinical judgements that state that a person, family, or community
is ready to advance from one level of health to another. Two components that must be
present are a desire for a higher level of wellness and an effective present status or
function.
✓ Readiness for enhanced…. (family coping, health maintenance, self-esteem, ect.)
• Syndrome nursing diagnosis – Compromised of a cluster of actual or risk nursing
diagnosis predicted to be present because of a specific situation or certain event. (PTSD)
3. Planning is the third step, during planning the nurse identifies outcomes and formulates goals
for the patient, family or community. Outcomes should be specific, measurable, attainable,
reasonable and time-specific. (S.M.A.R.T)
• Informal planning may occur at any time such as an emergency or simply when a nursing
is thinking about how they could better help their patient. Informal planning if formal
planning without documentation.
• Outcome identification and planning allows the nurse to set priorities, identify expected
patient outcomes, select necessary interventions to achieve these outcomes and
communicate the plan of care among the patient, family and other staff involved in the
patients care.
• Initial planning – preformed by the nurse along with the initial assessment. A
comprehensive plan that addresses each problem listed in the prioritized nursing
diagnoses and identifies appropriate patient goals and the related nursing care.
• Ongoing planning – This planning is completed each time the nurse interacts with the
patient. Data is collected to ensure the plan or care is kept up to date to resolve
identified health problems, manage risk factors and promote function. During ongoing
planning nursing diagnosis may be clarified or modified and new planning may be
implemented.
• Discharge planning – Ensures that the patient and family outcomes and needs are met as
the patient moves from a care setting to home, or from on care setting to another.
Education about continuity of care at home or in another health care setting is provided
by the nurse upon discharge.
• Care planning may include standardized templates set on the EHR, concept mapping,
ISBARR during patient hand-off, and clinical pathways.
4. Intervention/Implementation is the fourth step in which the nurse carries out actions that were
set for the patient in the planning step of the nursing process.
