The Nursing Process
This is the systematic method nurses use to identify patient needs and provide individualized care.
The nursing process
This is the process of purposeful, informed thinking that helps nurses make safe decisions.
Critical thinking
This model is used by the NCLEX to evaluate how well nursing students make safe clinical decisions.
Clinical Judgment Measurement Model (CJMM)
This priority-setting principle means airway problems usually come before breathing, circulation, pain, or teaching needs.
ABC: Airway, breathing, circulation
A patient says, “I feel dizzy.” The nurse checks the blood pressure and pulse. This is an example of this nursing process step.
Assessment
These are the five major components of the nursing process.
assessment, nursing diagnosis, planning, implementation, and evaluation
This term refers to the thinking process nurses use to understand patient problems and determine appropriate actions.
Clinical reasoning
In the CJMM, this step involves identifying important and relevant patient information.
Recognizes cues
A patient with chest pain should usually be seen before a patient asking for discharge instructions because chest pain may indicate this type of problem.
Urgent or life-threatening problem
A nurse notices a patient has new confusion, weakness, and slurred speech. The nurse recognizes these as important patient data, also called this.
Cues
During this step of the nursing process, the nurse collects subjective and objective data.
Assessment
This term refers to the nurse’s final decision or conclusion about a patient’s needs or care.
Clinical judgment
In the CJMM, this step involves deciding which patient problem is most important.
When setting priorities, the nurse should consider Maslow’s hierarchy, safety needs, patient condition, available resources, and this important factor.
The urgency of the patient's problem
A nurse identifies that a patient is at risk for falls because of weakness, dizziness, and a history of falling. This is an example of forming this.
Nursing diagnosis
During this step, the nurse determines whether the patient’s goals and outcomes have been met.
Evaluation
The nurse asks, “What information do I have, what does it mean, and what should I do next?” This is an example of this type of thinking.
Clinical reasoning
In the CJMM, this step involves determining whether the nursing action worked.
Evaluate outcomes
A patient who is confused and trying to climb out of bed is a high priority because this patient is at risk for this.
Injury or falls
A nurse decides to place the call light within reach, apply nonskid socks, and keep the bed in the lowest position for a fall-risk patient. This is an example of this nursing process step.
Planning
A nurse teaches a patient how to use an incentive spirometer after surgery. This action belongs to this step of the nursing process.
Implementation
A nurse improves clinical judgment by reflecting after patient care and asking, “What went well, what did I miss, and what would I do differently next time?” This practice is called this.
Reflection
The nursing process and the CJMM are similar because both require the nurse to do this before taking action.
The nurse has four patients. One has shortness of breath, one needs a bath, one requests pain medication, and one needs routine discharge teaching. The nurse should assess this patient first.
Shortness of breath
A nurse cares for four patients. One has a blood glucose of 52 mg/dL, one needs morning medications, one requests a blanket, and one is waiting for lab results. The nurse should care for this patient first.
Blood glucose of 52 mg/dL