Chapter 1, Critical Thinking Health (WHO, 2006)

Professional  Purposeful, reflective, goal-

directed cognitive process
 Complete physical, mental,
social well-being
Nursing Practice  Used to develop conclusions,
solutions, alternatives
 Not just absence of disease or
infirmity

Ethics Health Informatics

Key Terms and  Formal, systematic process to  Use of health IT to improve
Definitions in Nursing analyze decisions about quality, efficiency, delivery of
right/wrong healthcare
and Healthcare  Focus on well-being

Assessment Health Promotion

Evaluation
 Focus on wellness by changing
 Systematic data collection via
 Assess patient response to habits, lifestyle, environment
interview, observation,
nursing interventions  Aim: Reduce risks, enhance
examination
 Measure extent to which health
 Purpose: Determine patient
outcomes are achieved
health status, identify
actual/potential problems Implementation
Evidence-Based Practice
 Carrying out nursing care plan
Bundle (EBP) through interventions
 Set of 3 to 5 evidence-based  Best practice based on valid,
practices reliable research Interprofessional
  Considers setting, patient
Proper implementation Collaborative Practice
improves patient outcomes preferences, values, clinical
measurably judgment
  Multiple health professionals  Managed by independent
Moral Problem nursing interventions
working with patients, families,
communities
 Competing moral claims with
 Goal: Deliver best practices and
one principle clearly Nursing Process
optimal outcomes
dominating
 Systematic problem-solving
Morality Moral Uncertainty approach
 Steps: Assessment, diagnosis,
 Specific beliefs/actions planning, implementation,
 Internal conflict not knowing
evaluated by principles like evaluation
applicable moral principles but
autonomy, beneficence,
sensing something is wrong
nonmaleficence, double effect, Patient
distributive justice
Nursing (ANA, 2015b)  Traditional term for someone
Moral Dilemma  Protection, promotion,
receiving healthcare
optimization of health and
 Conflict between two or more Planning
abilities
ethical principles requiring a
 Prevention of illness/injury,
choice
facilitation of healing,  Developing measurable goals,
alleviation of suffering outcomes, care plan
Moral Distress  Diagnosis and treatment of  Aim: Resolve diagnosed
human responses problems and achieve goals
 Knowing right ethical action but  Advocacy for individuals,
unable to act on it families, groups, communities, Precision Medicine
populations
Moral Integrity  Use of research, technology,
Nursing Diagnosis policies for individualized care
 Virtues: veracity, fidelity, plans
benevolence, wisdom, moral  Clinical judgment about actual  Focus on disease prevention
courage or potential health problems and treatment
Quality and Safety
Education for Nurses
(QSEN)
 Project to prepare nurses with
knowledge, skills, attitudes
 Focus on quality, safety,
patient-centered care,
teamwork, EBP, quality
improvement, informatics

Telehealth
 Use of technology to deliver
healthcare, information,
education remotely

The Joint Commission

 Nonprofit accrediting hospitals
and healthcare organizations

Wellness
 Ability to perform well, adapt,
feel well and harmonious
  Advocacy for individuals,  Engage in education and
Notes: Nursing - An families, groups, communities, training.
Evolving Profession and populations.  Participate in patient and
health systems management.
 Influence and shape health
Historical Foundation Key Responsibilities of
policy.
 Florence Nightingale (1858)
Nurses
viewed nursing’s goal as
 Adherence to Nursing’s Social
optimizing patient condition for
Policy Statement (ANA, 2010;
natural healing.
Fowler, 2015).
 Nursing recognized as both an
 Compliance with state nurse
art and a science since
practice acts.
Nightingale’s time.
 Following the Code of Ethics for
Nurses (ANA, 2015a) and
Modern Definition International Council of Nurses
(American Nurses (ICN, 2012).

Association - ANA, Additional Roles of

2015b) Nurses (ICN, 2012)
Nursing is defined as:
Beyond direct patient care, nurses
also:
 Protection, promotion, and
optimization of health and
 Advocate for patients and
abilities.
communities.
 Prevention of illness and injury.
 Promote a safe healthcare
 Facilitation of healing.
environment.
 Alleviation of suffering through
 Conduct and participate in
diagnosis and treatment of
research.
human responses.
 o Citizen of the  Meeting essential needs allows
Notes: The Patient - community progression to higher-priority
Consumer of Nursing and needs.
Health Care Collaborative Approach
Hierarchy Levels
 Patients are increasingly
Terminology Evolution knowledgeable healthcare
(Pyramid Structure)
consumers.
 Patient: From Latin "to suffer", 1. Physiologic Needs: Basic
 They expect a collaborative
implies dependence. survival needs (e.g., food,
relationship with nurses to
 Client: From Latin "to lean", water, shelter).
achieve optimal health (Majid
suggests alliance and 2. Safety and Security: Feeling
& Gagliardi, 2019).
interdependence; preferred by safe from harm, stability.
many nurses. 3. Sense of Belonging and
 Current Usage: "Patient" Nurse’s Role in Affection: Social connections,
remains widely used by Healthcare Delivery love.
clinicians and organizations 4. Esteem and Self-Respect:
(e.g., IPEC, 2016a). Feeling valued, self-worth.
 Identify patient’s immediate,
5. Self-Actualization: Highest
ongoing, and long-term needs.
Holistic View of the level; self-fulfillment, desire to
 Collaborate with the patient to
learn, aesthetic needs.
address these needs effectively.
Patient
 Patient is more than someone The Patient’s Basic Significance for Nursing
with health problems (often Needs: Maslow’s  Lower-level needs remain
multiple comorbidities).
Hierarchy of Needs important at all times.
 Also a:
 Pursuit of higher-level needs
o Individual person
indicates psychological health
o Family member Foundation and well-being.
o Member of social
groups  Basic needs exist for all people.
 Framework helps nurses assess
patient strengths, limitations,
and guide interventions.
  Definition:  Focus Areas:
Notes: Health, Wellness,
Health Promotion, and Considered equivalent to Encouraging changes in
health; involves proactive self- personal habits, lifestyle, and
Health Care care for physical, psychological, environment to reduce risks
social, and spiritual well-being. and enhance health.
Health
 Key Components:  Patient Empowerment:
 Definition (WHO, 2006): 1. Capacity to perform at o Self-care wellness
one’s best ability. education programs on
"A state of complete physical, 2. Ability to adjust and health promotion,
mental, and social well-being, adapt to changing disease prevention,
not merely the absence of situations. illness management,
disease or infirmity." 3. Reported feeling of and professional care
well-being. use.
 Implications: 4. Feeling of harmony and o Online resources
integration ("everything (websites, chat groups,
Health and illness are not is together"). social media) for
opposites; a person can have  Nursing Focus: experience sharing.
illness yet maintain health in o Mobile technologies
other domains (mental, social). Nurses promote positive health (e.g., Fitbit) and
changes, recognizing wellness is informatics tools (e.g.,
 Criticism: subjective and individualized. Carb Manager)
personalize health
The definition is seen as
idealistic since "complete" well-
Health Promotion promotion.
 Impact of Mobile Health Apps:
being in all areas is rarely
 Modern Emphasis:
achievable. Positive effects on physical
Focus on health, wellness, and activity, diet, medication
Wellness self-care as outcomes of a adherence, knowledge, leading
wellness-oriented lifestyle. to improved clinical outcomes.
  Primary Health Care (WHO, dieticians, social workers,
2019): psychologists, therapists.

Comprehensive care including

promotion, prevention,
treatment, rehabilitation,
palliative care close to daily
environments.

Emphasizes lifelong
commitment, empowerment,
and societal health policy.

Health Care
 Description:

Services to individuals, families,

and communities to maintain
health, prevent/manage illness,
and support rehabilitation,
recovery, and palliative care.

 Settings and Providers:

Delivered in inpatient,
outpatient, and community
settings by diverse
professionals: nurses, primary
providers, pharmacists,
  Major public health issues:
Notes: Influences on Population tobacco, substance abuse, poor
Health Care Delivery Demographics diet, inactivity, obesity.
 Healthcare focus shifting from
 U.S. population growing (329+ curing disease to health
Key Factors Driving million in 2020) with changing promotion, prevention, and
Change composition. chronic illness management.
 Aging population: fewer  Nurses play key roles in
 Shifting Population children, more seniors (many managing chronic illness and
Demographics: Changes in size women). disability.
and composition, including  Urbanization and migration
aging and urbanization. concentrate populations in
 Changing Patterns of Disease cities; ethnic minorities
Healthy People 2030
and Wellness: Rise in chronic increasing. Initiative
diseases and shift toward  Poverty and homelessness
health promotion and rising; 568,000 homeless in  Aims to improve U.S.
prevention. 2019 with minorities population health through
 Advances in Technology and disproportionately affected. goals set over decades.
Genetics: Innovations like  Healthy People 2020 focused
robotics, genomics, precision Changing Patterns of on access, environment,
medicine. prevention, nutrition, physical
 Emphasis on Quality, Costs, Disease and Wellness activity, social determinants,
and Reform: Focus on and reducing injury, violence,
improving care quality while  Chronic diseases obesity, tobacco, substance
managing expenses. (cardiovascular, cancer, abuse.
 Interprofessional Collaborative diabetes, lung diseases) cause 7  Healthy People 2030
Practices: Enhanced teamwork of 10 leading deaths. emphasizes collaboration,
among healthcare  Nearly half of adults have one reducing disparities, improving
professionals. chronic condition; 60 million equity and health literacy.
have two or more.  Data-driven objectives guide
ongoing healthcare reforms.
  Key technologies: AI,
Advances in Technology blockchain, cloud computing,
Additional Context from
and Genetics disease management tools, 2025 Healthcare Trends
EHR interoperability.
 Rapid progress in medical  TIGER Initiative: Guides  Shift toward patient-centered,
technology and genetics. integration of HIT into nursing digitally integrated care models
 Robot-assisted surgeries and practice. with virtual triage and
outpatient procedures  International Classification of monitoring.
increasing. Diseases (ICD):  Increased use of wearable
 Genetics/genomics enable o ICD-10 used in U.S. since devices and AI for early
expanded screening, 2015 for disease coding detection and personalized
diagnostics, and treatments. and reimbursement. management.
 Precision Medicine Initiative o ICD-11 released in 2018  Growth in outpatient and
(PMI): for global adoption. home-based care driven by
o Launched 2015 to  Electronic Health Records patient preference and
create individualized (EHRs): technology.
care plans using o CMS mandates EHR use;  Emphasis on mental health
genomics and data Promoting integration and virtual intensive
analytics. Interoperability outpatient programs.
o Immediate focus on Program enforces  Challenges include staffing
cancer adoption. shortages, rising costs,
prevention/treatment;  Telehealth: regulatory burdens, and need
long-term potential for o Remote delivery of for value-based care models.
many diseases. healthcare, information,  New entrants like Amazon
education. offering virtual and in-person
Health Informatics o Includes real-time primary care, expanding access.
communication (e.g.,  Digital transformation and
video consults) and interoperability critical for
 Interdisciplinary field using
store-and-forward (e.g., efficient, coordinated care
health IT to improve care
image transmission). delivery.
quality, efficiency, delivery.
Quality, Safety, and 2. Effective: Provide scientifically into patient care to ensure
supported services to those quality.
Evidence-Based Practice who benefit; avoid ineffective
in Nursing care. Evidence-Based Practice
3. Patient-centered: Respect and
respond to individual patient Bundles
Initial Concerns (IOM preferences, needs, values.
4. Timely: Reduce waits and  Developed by the Institute for
Reports) Healthcare Improvement (IHI).
harmful delays for patients and
providers.  Sets of 3-5 EBPs designed to
 To Err Is Human (2000):
5. Efficient: Avoid waste of measurably improve patient
resources, supplies, ideas, outcomes.
Revealed nearly 100,000 annual
energy.  Many bundles fall within
deaths from preventable
6. Equitable: Ensure care quality independent nursing scope
hospital errors in the U.S.
does not vary by gender, (e.g., Ventilator Bundle: head-
ethnicity, location, of-bed elevation, chlorhexidine
 Crossing the Quality Chasm
socioeconomic status. oral care).
(2001):
 Other EBP Tools:
o Clinical guidelines
Described healthcare as Principles of Evidence- o Algorithms (acute care
inefficient, fragmented,
inequitable, inaccessible; called
Based Nursing Practice decision-making)
o Care mapping
for evidence-based, systems- (EBP) o Multidisciplinary action
oriented reform.
plans (MAPs) for care
 Definition: Best practice based
coordination
Six Aims for on valid, reliable research;
o Clinical pathways
integrates research, healthcare
Improvement (IOM, setting, patient preferences,
 Nurses play key roles in
developing, piloting,
2001) and clinical judgment.
implementing, revising these
 Process: Identify, evaluate, and
tools.
1. Safe: Avoid patient injuries incorporate current research
from intended care.
 o Teamwork and  Aims of Update:
Quality and Safety collaboration o Standardize language
Education for Nurses o Evidence-based practice across professions
o Quality improvement o Improve assessment
(QSEN) o Safety and outcome evaluation
o Informatics o Address contemporary
 Funded by Robert Wood
 IPEC Response healthcare goals with
Johnson Foundation.
(2011): Published Core focus on population
 Prepares nurses with
Competencies for health
knowledge, skills, attitudes
Interprofessional Collaborative  Vision
(KSA) to improve healthcare
Practice to prepare students for Maintained: Collaborative
quality and safety.
teamwork aimed at safer, practice is key to safe, high-
 Core Competencies:
better patient-centered care. quality, patient-centered care.
o Patient-centered care
 Definition: Multiple health  Nursing Role: Nurses are vital
o Teamwork and
professionals working with members of interprofessional
collaboration
patients, families, communities teams, highlighted through
o Evidence-based practice
to deliver best practices and critical thinking exercises.
o Quality improvement
optimal outcomes.
o Safety
 IPEC Update (2016):
o Informatics
 Integrated into nursing
Organized competencies under
education via case studies.
"interprofessional
collaboration" domain:
Interprofessional
Collaborative Practice o Values/ethics for
practice
o Roles and
 IOM Challenge (2003): Health
responsibilities
professions education must
o Communication
integrate interdisciplinary core
practices
competencies:
o Teamwork and team-
o Patient-centered care
based practice
  Provides tools for sound
Notes: The Practice of Critical Thinking: decisions and quality care.
Nursing and Critical Definition and
Thinking Components Metacognition
 Purposeful, insightful,  Critical thinking includes
Increasing Complexity in reflective, goal-directed metacognition: examining
Nursing Practice cognitive process. one’s own reasoning to
 Involves reasoning, judgment, improve thinking skills.
 Nurses face complex challenges and analysis based on  Independent nursing
due to: knowledge. judgments come from strong
o Scientific advances  Leads to appropriate knowledge and ability to
o Higher patient acuity in conclusions, solutions, and synthesize information
diverse settings alternatives. contextually.
o Aging population
o Complex diseases and
Importance in Nursing Characteristics of Critical
end-of-life issues
o Ethical and cultural Thinkers
 Enables patient-centered care
factors
plans.
 Inquisitive, open to
 Recognized as a core
alternatives.
Need for Critical Thinking competency by NLN and AACN.
 Possess habits of mind:
 Fundamental for effective
confidence, perseverance,
 Essential for multifaceted nursing process and clinical
inquisitiveness, intuition,
problem-solving and decision- reasoning.
flexibility, creativity, intellectual
making based on ethical  Enhances clinical decision-
integrity, contextual
principles. making to identify patient
perspective, open-mindedness,
needs and best actions.
reflection.
 Described as systematic
thinking and reflection ensuring
safe practice. Clinical Reasoning
  A method of critical thinking  Demonstrate humility and seek
leading to clinical judgment and
Reflective and more information.
nursing actions. Comprehensive Nature  Seek innovative approaches.
 Core of the nursing process.  Practice bracketing: detach
 Influenced by communication,  Reflective thinking involves personal bias for objectivity.
education, knowledge, awareness and active  Go beyond problem-solving to
environment familiarity, evaluation. explore all relevant factors and
experience, professionalism.  Nurses consider cultural think "outside the box."
differences and personal  Intellectual integrity is key in
Development of Critical biases. pursuing best practice.
 Critical thinkers are insightful,
Thinking fair, courageous, perseverant Critical Thinking and
to minimize biases.
 Skills develop over time with Clinical Reasoning in
effort, practice, and Components of Critical
experience.
Nursing Practice
Thinking in Nursing
Rationality and Insight in Relationship Between
 Prioritize patient-centered care
Critical Thinking plans.
Critical Thinking and
 Gather and validate accurate Clinical Reasoning
 Key skills: interpretation, data.
analysis, inference,  Analyze information for  Critical thinking and decision-
explanation, evaluation, self- significance and patterns. making improve clinical
reflection, self-regulation.  Use diverse thinking: logic, expertise.
 Requires strong knowledge, experience, knowledge,  Critical thinking is the
understanding, logical thinking. intuition. foundation of clinical reasoning
 Nurses validate data accuracy,  Maintain flexibility and inquiry. and clinical judgment.
evaluate actions, question  Reason inductively and  Clinical reasoning involves
inconsistencies. deductively. gathering, analyzing patient
 Iterative process involving  Formulate creative, information, evaluating
repetition and refinement. independent decisions. significance, and weighing
 alternative actions to provide o Recognizing  Differentiate complications
optimal care. assumptions, from expected symptoms.
inconsistencies, biases  Work with interprofessional
o Verifying data reliability teams to modify treatment
Human Factors and
and accuracy plans.
Practice Settings o Identifying missing
information Development of Critical
 Developing nursing care plans o Distinguishing relevant
requires considering human vs. irrelevant data Thinking Skills
factors: interactions with o Supporting evidence
patients, families, and with facts  Developed through experiential
healthcare providers. o Prioritizing and timely learning and practice.
 Critical thinking is essential in decision-making  Exercises focus on evidence-
all settings: acute, ambulatory, o Setting patient-specific based practice, priority
extended care, home, and outcomes assessments, interventions, and
community. o Reassessing responses collaboration.
 Each patient situation is unique and outcomes  Ethical principles and cultural
and dynamic, requiring  These skills rely on a solid contexts often influence
individualized analysis and knowledge base and logical decision-making.
evaluation. reasoning.
The Nursing Process
Cognitive and Example: Oncology
Metacognitive Skills in Nursing Definition
Decision-Making  A deliberate, systematic
 Use evidence-based guidelines
to manage therapy problem-solving approach
 Skills include:
complications. addressing healthcare and
o Systematic and
 Collaborate with nursing needs.
comprehensive
assessment patients/families to understand
treatment impact. Traditional Five Steps
1. Assessment: ANA Addition: Outcome Description /
o Collect data via
Step
Actions
interview, observation, Identification record review, data
examination. organization and
o Analyze data to  Identifying expected patient analysis
determine health status outcomes before planning.
 Revised sequence: assessment, Identify nursing
and problems.
diagnosis, outcome problems
2. Diagnosis:
identification, planning, (signs/symptoms,
o Nursing diagnoses:
implementation, evaluation. Diagnosis causes),
clinical judgments on
collaborative
responses manageable
problems, and team
by nurses. Integrated and Iterative members involved
o Collaborative problems:
physiological issues Nature Prioritize diagnoses,
requiring joint set realistic
management with  Nursing process steps are measurable goals,
physicians. interrelated, interdependent, identify
Planning
3. Planning: and recurrent. interventions and
o Develop measurable  Requires critical thinking and outcomes, involve
goals and care plans to ethical consideration for patient/family/team,
resolve problems and comprehensive care. keep plan flexible
achieve outcomes. Execute
4. Implementation: Summary Table of interventions,
o Carry out nursing Implementation coordinate care,
interventions. Nursing Process Steps document patient
5. Evaluation: responses
o Assess patient Description / Collect current data,
Step
responses and extent of Actions compare actual vs.
outcome achievement. Health history, Evaluation expected outcomes,
Assessment physical exam, involve
family interviews, patient/family/team,
 Description / o Approach influences o Patient’s family/significant
Step quality and quantity of others.
Actions
information. o Other healthcare team
revise plan as o Build mutual trust and members.
needed, continue respect using therapeutic o Patient’s Electronic Health
cycle communication Record (EHR).
techniques. o Past medical history or
 Tools: Health history guides or previous admission
Assessment in Nursing interview formats adapted to records.
(Detailed) patient’s responses and needs.  Flexibility: Sequence of gathering
information may vary based on
patient needs.
Types of Assessment Physical Assessment  Nurse’s Responsibility: Use all
relevant data sources for a
 Initial/Baseline Assessment:  Timing: Before, during, or after comprehensive assessment.
o Systematic collection of health history depending on
predetermined data at patient’s status and priorities.
first patient contact.  Purpose: Identify physical, Recording the Data
o Includes health history psychological, emotional states
and physical assessment. indicating nursing care needs.  Process: Document health history
 Ongoing Assessment:  Techniques: and physical assessment in
o Continuous monitoring to o Use of senses: sight, patient’s permanent record.
detect changing patient hearing, touch, smell.  Electronic Health Records
needs and evaluate o Interview skills and (EHRs): Increasingly used for
nursing care effectiveness. physical examination documentation.
techniques.  Patient Privacy (ANA Advocacy):
o Assess behaviors and role o Patients should be
Health History changes. informed about how their
health records are used
 Purpose: Determine patient’s and disclosed.
wellness or illness status.
Other Components of o Confidentiality must be
 Method: Planned interview—a Assessment strictly maintained.
personal dialogue between nurse  Functions of Records:
and patient to gather information.  Additional Information Sources: o Facilitate communication
 Nurse’s Role: among healthcare team.
 o Support coordinated Techniqu Therapeuti Techniqu Therapeuti
planning and continuity of Definition Definition
e c Value e c Value
care.
o Serve additional expressed by reinforces discussion patient’s
administrative and legal patient. important topics. initiative.
functions. points. Promotes
Shows insight,
Use of comic
Therapeutic Directing empathy,
enjoyment to
resolves
patient’s interest, Humor tension,
Communication Reflectio
feelings, ideas, respect;
discharge
reveals
n energy.
Techniques or questions validates new
back to them. understand options.
ing. Useful for
Techniqu Therapeuti
Definition Enhances health
e c Value Informin Providing
understand teaching
Active process Shows Asking patient g information.
ing of and patient
of receiving nurse’s to explain
Clarificati patient’s education.
Listening information interest vague or
on feelings Asking patient
and examining nonverball unclear
and to verify Clarifies
reactions. y. thoughts.
perception Sharing nurse’s communic
Allows s. Percepti understanding ation,
patient
Keeps ons of their promotes
Periods without time to
Questions/stat communic thoughts/feelin reflection.
verbal think,
ements to ation goal- gs.
Silence communication encourages
Focusing expand on directed, Helps
for therapeutic conversati
ideas or explores Recognizing explore
reasons. on, Theme
feelings. central recurring and
conveys Identifica
issues. underlying understand
support. tion
Encouraging Shows patient issues. important
Validates Broad
Repeating main patient to acceptance problems.
Restating nurse’s Openings
thought or idea select and values
listening,
Techniqu Therapeuti o Define the scope of  What Nursing Diagnoses
Definition nursing practice. Represent:
e c Value
o Included in state nurse o Actual or potential health
Offering Increases practice acts, ANA’s Scope problems.
alternative patient’s and Standards of Practice o Health promotion states.
Suggesti
ideas for options (2015b), and specialty o Potential risks
ng
problem- and nursing standards. manageable by
solving. choices. o Continuously validated independent nursing
and updated to reflect actions.
current practice and  Distinction from Medical
Diagnosis in Nursing research. Diagnoses:
 Key Organizations: o Nursing diagnoses are not
o NANDA International medical diagnoses or
Basis of Diagnosis (NANDA-I): First official treatments.
nursing diagnosis o They are concise
 Nursing diagnoses and organization. statements guiding
collaborative problems are based o International nursing care plans.
on data collected during Classification for Nursing  Components of a Nursing
the assessment phase. Practice Diagnosis:
 Nurses organize, analyze, (ICNP®): Alternative o Defining
synthesize, and summarize health taxonomy supporting Characteristics: Signs and
history and physical assessment nursing care and symptoms that describe
data to identify patient care
documentation, updated the problem.
needs. through 2019. o Etiology (Related
 Choosing a Nursing Diagnosis: Factors): Causes or
Nursing Diagnoses o Identify common patterns contributing factors.
in assessment data. o Example (Anemia):
 Role and Significance: o Categorize related data  Activity
o First taxonomy specific to revealing a problem intolerance
nursing. requiring nursing related to oxygen
o Promote nursing intervention. supply-demand
autonomy and o Define specific nursing imbalance.
accountability. diagnoses based on these  Impaired
problems. peripheral tissue
 perfusion related o Recommend and o Identify interdependent
to decreased implement appropriate (collaborative)
hemoglobin. nursing interventions. interventions.
 Impaired  Key Distinction: o Document all elements
nutritional status o Collaborative problems do (diagnoses, problems,
related to fatigue not have patient goals. outcomes, goals,
and inadequate o Evaluation approaches interventions) in the care
nutrient intake. differ from nursing plan.
diagnoses. o Communicate needs best
met by other healthcare
Collaborative Problems team members.
Planning
 Definition:
o Problems or complications  Definition: Setting Priorities
of medical origin that do
not fit nursing diagnosis Begins after nursing diagnoses  Collaborative process involving
criteria. are identified; involves nurse, patient, and family.
o Require collaboration with  Resolve disagreements mutually.
developing a plan of care.
primary providers and  Prioritize based on urgency; most
healthcare team. critical problems get highest
 Overall Process:
 Nurses’ Role: priority.
o Assign priorities to nursing
o Monitor for onset or  Use Maslow’s Hierarchy of
diagnoses and
changes in physiologic Needs as a prioritization
collaborative problems.
complications. framework.
o Specify realistic,
o Manage complications
measurable expected
with both nurse-
prescribed and provider-
outcomes. Establishing Expected
o Set immediate,
prescribed interventions.
intermediate, and long- Outcomes
 Focus:
term goals.
o Detect complications  Written as patient behaviors with
o Identify specific nursing
related to disease, timeframes.
interventions to achieve
treatments, medications,  Must
outcomes.
or diagnostics. be attainable and quantifiable.
 Resources:
 o ICNP (International  Continuous Assessment: Monitor
Classification for Nursing
Determining Nursing patient responses and condition.
Practice) Actions  Plan Revision: Update care plan as
o Nursing Outcomes patient’s status or priorities
Classification (NOC)  Individualized interventions based change.
o Agency-specific criteria on patient needs and preferences.  Actions: Direct or indirect nursing
 Outcomes define desired patient  Specify activities, responsible interventions.
behaviors, measure progress, persons, and frequency.  Purpose: Resolve nursing
evaluate intervention  Collaborate with interdisciplinary diagnoses, manage collaborative
effectiveness, and guide care plan team for integrated care. problems, achieve outcomes,
revisions.  Include patient education for self- meet health needs.
care.  Example: Supervising patient
performing active range-of-motion
Establishing Goals  Consider ethical, cultural, age,
exercises three times daily.
developmental, and gender
 Set after priorities and expected factors.
outcomes.  Use standardized interventions Evaluation in the Nursing
 Include immediate, intermediate, (e.g., NIC, ICNP) but tailor to
and long-term goals. patient. Process
 Base actions on established
 Patient and family involvement is
nursing standards.
essential. Definition and Purpose
 Examples:
o Immediate: Stand at Implementation  Evaluation: The final step of the
bedside for 5 minutes nursing process.
within 6-12 hours post-  Definition: Execution of the  Purpose:
surgery. nursing care plan. o Determine patient’s
o Intermediate: Ambulate  Nurse’s Role: response to nursing
15-20 minutes with walker o Responsible for carrying interventions.
in hospital/home. out the plan. o Assess extent to which
o Long-term: Ambulate o Coordinates care among objectives/outcomes have
independently 1-2 miles patient, family, and been achieved.
daily. healthcare team.
 Guided By: Immediate,
intermediate, and long-term goals.
Basis for Evaluation
  The plan of nursing care guides  Are there new problems without o Indicate whether
evaluation. planned or implemented outcomes were met.
interventions? o Include any additional
 What factors influenced relevant data.
Focus Areas for achievement or lack thereof of  Individualized Plan: Tailor plan of
Evaluation objectives? care to each patient’s unique
 Is there a need to change circumstances.
 Nursing diagnoses expected outcomes or criteria?  Plan Revision:
 Collaborative problems o Update plan as patient
needs change, priorities
 Priorities Data Collection shift, problems resolve, or
 Nursing interventions
 Expected outcomes new information arises.
 Collect objective data from: o Evaluate and document
o Patient patient responses
Key Questions During o Family/significant others continuously.
o Healthcare team members o Revise plan accordingly.
Evaluation  Data must be substantiated by  Assurance: Continuous updates
direct patient observation before ensure nursing diagnoses and
 Are nursing diagnoses and documentation. collaborative problems are
collaborative problems accurate?  Include data in patient records. addressed and patient needs met.
 Have expected outcomes been
achieved within critical
timeframes?
Documentation of Frameworks for a
 Are patient’s nursing diagnoses Outcomes and Plan Common Approach to
resolved?
 Are collaborative problems Revision Nursing
resolved?
 Is there a need to reorder  Outcome Documentation:  Purpose: Use
priorities? o Concise and objective. frameworks/taxonomies to guide
 Are patient’s nursing needs being o Link outcomes to nursing diagnoses, outcomes,
met? diagnoses and interventions, and clinical
 Should nursing interventions collaborative problems. decision-making.
continue, be revised, or o Describe patient
discontinued? responses to
interventions.
 Desirable Framework: Common
language across all nursing aspects
regardless of classification system.
 Harmonization:
o NANDA-I (diagnoses), NIC
(interventions), and NOC
(outcomes) linked in a
consistent taxonomy
(2001).
o ICNP catalogs align
diagnoses, outcomes, and
interventions.
 Benefits:
o Facilitates clinical
judgment and critical
thinking.
o Matches interventions and
outcomes accurately with
nursing diagnoses.
 NCSBN Clinical Judgment
Measurement Model:
o Developed by National
Council of State Boards of
Nursing.
o Framework to measure
clinical decision-making
and judgment.
o Applied in NCLEX-RN
examination context.
 behaviors examined
Ethical Nursing Care Ethical Issues in Resource through ethical analysis.
Allocation
Context and Importance Ethics Theories
 Unjust allocation based on age,
 Nurses frequently encounter race, gender, disability, or social
complex ethical issues in norms is problematic. Teleologic Theory
healthcare.  Older adults may face denial of
 Growing interest in ethics due to care due to ageism.
(Consequentialism)
advances in technology, genomics,
medical futility, resource scarcity,  Focuses on consequences of
and end-of-life concerns.
Ethical Dilemmas in actions.
 Utilitarianism: Action is right if it
 Ethical awareness helps nurses Nursing produces the greatest good for
navigate dilemmas and provide
compassionate, just care. the greatest number.
 Occur across all settings, requiring  Challenges include judging
understanding of moral intrinsic values, defining whose
Impact of Technology philosophy, ethics principles, and good matters most, and whether
nursing roles. good ends justify questionable
 Nurses must articulate ethical
 Advanced technology prolongs life means.
but may not guarantee quality of positions, develop decision-
making skills, and apply nursing
life.
 Examples: robotic aids for chronic process ethically. Deontologic (Formalist)
conditions, LVADs for heart Theory
failure, immunotherapy for Ethics vs. Morals
cancer, organ/stem cell  Ethical standards exist
transplants.  Often used interchangeably but independently of outcomes.
 Raises questions about when and differ slightly:  Nurses have a duty to act
how to use technology ethically. o Ethics: Formal, systematic according to ethical principles
 Some patients benefit; others may study of moral beliefs regardless of consequences.
endure prolonged suffering with about right and wrong.  Challenges include personal and
emotional and financial burdens. o Morality: Personal or cultural biases influencing
societal values and principle choice.
 compassion, advocacy,  Focuses on understanding the
Core Ethical Principles in accountability, self-care, ethical concepts, language, and
Nursing (from ANA and work environments, professional foundations of ethics itself.
advancement, collaboration, social  Examines questions like the
other sources) justice, and global health. meaning and justification of moral
 Emphasizes respect for human terms and principles.
 Autonomy: Respecting patients’ dignity, patient-centered care,  Example in healthcare: Analyzing
rights to make informed decisions shared decision-making, and the concept of informed consent—
based on their values and beliefs. cultural sensitivity. beyond knowing consent is
 Beneficence: Advocating for  Nurses must maintain ethical required, questioning if the
patients’ best interests and competence through ongoing patient is truly informed and
providing compassionate, person- education and self-reflection. competent.
centered care.  Nurses advocate for social justice  Meta-ethics is more abstract and
 Justice: Ensuring equitable care and work to reduce health analytical, dealing with what
regardless of age, race, gender, disparities. morality is rather than what is
socioeconomic status, or other moral.
factors.
 Nonmaleficence: Commitment to Ethical Nursing Practice
do no harm and minimize risk in
Applied Ethics
patient care.  Nurses balance respect for patient
 Fidelity: Maintaining trust and values with harm mitigation.  Deals with identifying and
professional boundaries.  Ethical decisions are unique and addressing ethical problems
 Accountability: Taking situational, requiring compassion specific to a discipline or practice.
responsibility for nursing actions and integrity.  Applies general ethical theories
and decisions.  Nurses promote an ethical and principles to real-world moral
 Veracity: Being truthful and environment that supports safe, issues.
honest with patients. quality care and fosters trust in  Nursing ethics is a form of applied
nurse-patient relationships. ethics, focusing on moral
situations specific to nursing and
ANA Code of Ethics for patient care.
Approaches to Ethics in  Uses core ethical principles such
Nurses (2025 Edition)
Nursing as autonomy, beneficence,
nonmaleficence, double effect,
 Contains ten provisions guiding
and distributive justice to evaluate
ethical nursing practice, including Meta-ethics moral claims.
 institutional barriers, leading to  Ethical conflicts should be
Moral Situations in moral distress. presented logically and
Nursing systematically.
 Nursing emphasizes a holistic,
Ethical Dialogue and biopsychosocial-spiritual approach
 Moral Dilemmas: Conflicts
between two or more moral Collaboration with caring and compassion as
principles requiring a choice of the core virtues.
lesser evil.  Nurses must engage openly in  Nurses face both major ethical
 Moral Problems: Competing discussions about moral issues. dilemmas and everyday ethical
claims where one principle clearly  Interdisciplinary collaboration challenges (e.g., confidentiality,
dominates. improves when all team members restraints, truth-telling, refusal of
 Moral Uncertainty: Inability to can voice concerns. care, end-of-life decisions).
clearly define the moral issue or  Ethics committees can help
applicable principles, but sensing resolve dilemmas. Confidentiality
something is wrong.  Nurses should be familiar with
 Moral Distress: Knowing the right policies supporting patient  Awareness & Respect: Nurses
action but being unable to act due autonomy and ethical issue must recognize the confidential
to institutional constraints (e.g., resolution. nature of patient information and
poor ethical climate, lack of  Nurses have a moral obligation to respect each person’s privacy.
empowerment). address concerns constructively  Documentation: Only document
and advocate for patients. information pertinent to patient
Example of Moral care; avoid unnecessary details.

Distress Types of Ethical Problems  Private Discussions: Patient

information should be discussed
in Nursing only in private settings among
 Case of an older adult with healthcare team members.
dementia and aspiration  Accountability to society guided  Use of Interpreters: Family
pneumonia. by formal codes of ethics (e.g., ICN members or ancillary staff should
 Family conflict over feeding tube Code of Ethics, ANA Code of not be used as interpreters;
insertion despite evidence it does Ethics). professional services must be
not improve quality of life.  Nursing’s advocacy role requires provided to protect
 Nurse advocates against feeding active participation in ethical confidentiality.
tube but feels powerless due to decision-making.  Technology Risks: Electronic
Health Records (EHRs) and
 telehealth increase risk of  Risk-Benefit Analysis: Nurses advocate for patients, and
unauthorized access and data must weigh risks of restraints use ethics committees if
breaches. against potential injuries without needed.
 Data Access: Personal health them. o Disclosure
information is often accessible to  ANA Advocacy (2012): Staff must Manner: Compassion and
many individuals and entities, be educated on safe restraint use sensitivity are crucial;
raising misuse concerns. and monitor patients vigilantly. support from family or
 ANA Position: Nurses must  Last Resort: Restraints should only spiritual advisors may be
protect patient privacy and be used when no other options necessary.
confidentiality (ANA, 2015). are viable. o Revealing Diagnosis
 HIPAA (2003): Federal law  Regulatory Standards: The Joint Without Consent: HIPAA
protecting private health Commission and CMS set violation; unethical and
information (PHI) across all standards for restraint use. illegal breach of
transmission methods; violations confidentiality.
can lead to legal consequences.
 Best Practices:
Truth-Telling (Veracity)
o Share information only
Refusing to Provide Care
 Fundamental Principle: Essential
with authorized
to nurse-patient relationship;
and Related Ethical
individuals.
o Maintain confidentiality supports patient autonomy. Considerations in Nursing
even after professional  Non-Disclosure
relationship ends. Consequences: Withholding
o Avoid discussing patient diagnosis denies patient informed Refusing to Provide Care
info in public areas. decision-making.
o Obtain informed consent  Ethical Dilemmas:  Ethical Dilemma: Nurses may feel
before disclosing o Use of morally compelled to refuse care
information outside the Placebos: Acceptable only for certain patients.
healthcare team. with patient awareness  Reasons for Refusal:
and consent in research; o Conflict with personal
unethical otherwise. values or beliefs.
Restraints o Not Revealing o Fear of harm to patient or
Diagnosis: Causes moral self.
 Ethical Concerns: Use of physical distress; nurses should o Discomfort related to
or pharmacologic restraints limits avoid lying, provide patient’s ethnicity, sexual
patient autonomy and dignity. relevant information,
 orientation, or other o Manage pain and o Encourages advance
factors. suffering. directives (ADs).
 Ethical Obligation: o Facilitate end-of-life o Requires healthcare
o The ANA Code of Ethics discussions with patients facilities to inform
(2015a) mandates nurses and families. patients about ADs.
provide patient-centered o Provide palliative care  Advance Directives:
care to all patients focused on symptom o Legal documents
regardless of background relief, not hastening death specifying patient wishes
or condition. (ANA Provision 1.4). before hospitalization.
o Nurses must not refuse  Holistic Approach: Addresses o Include living wills and
care based on personal physical, emotional, spiritual designation of healthcare
biases. needs through interdisciplinary representatives.
 Patient-Centered Care: care. o May have limitations (e.g.,
o Care must be equitable applicability in
and respectful of all emergencies, EMS
patients, including those
Preventive Ethics recognition).
near end-of-life.  Physician Orders for Life-
o Support extends to family  Nurses have a moral responsibility Sustaining Treatment (POLST):
and surrogate decision- to choose the lesser of two evils o Addresses wishes of
makers. when faced with conflicting ethical seriously ill patients in
options. home settings.
 Such situations often cause moral o Legally recognized in many
End-of-Life Issues distress. states.
o Guides EMS on emergency
 Common Ethical Dilemmas: Pain
management, DNR orders, life
Patient Self- interventions consistent
with patient preferences.
support, feeding and hydration Determination
decisions.
 Challenges: Acceptance that  Dilemmas: Arise when patient
Ethics Committees
technology may prolong life but wishes are unknown or unclear
compromise comfort or dignity. (e.g., unconscious or mentally  Multidisciplinary groups assisting
 Nurse’s Role: incompetent patients). with ethical dilemmas in
o Advocate for patient rights  Patient Self-Determination Act healthcare settings.
and dignity. (1991):  Roles vary: policy development,
education, consultation.
  Consultations can occur bedside
or in meetings.
 Composed of ethics experts,
including nurses, physicians, social
workers, chaplains.
 Valuable resource for healthcare
teams, patients, and families.

Ethical Decision Making

 Nursing ethical dilemmas are
complex and varied.
 Guided by fundamental
philosophical principles.
 Moral reflection helps justify
nursing actions.
 Systematic approaches, such as
ethical analysis frameworks,
support resolution of dilemmas.
 Nurses can use the nursing
process steps to guide ethical
decision-making.