Burton
Fundamentals of Nursing Care 4e
Audio Chapter Summary
CH04
Chapter 4 – The Nursing Process: Critical Thinking, Decision Making and Clinical
Judgment
Each day in a health-care facility, you must be ready to find out the pertinent information
about the patient and develop an appropriate plan of care in a short period of time.
Nurses can make decisions using critical thinking and the nursing process. Nurses who
use critical thinking avoid jumping to conclusions about patients or care, and they avoid making
decisions based on assumptions. You must learn to think purposefully, using reasoning and
logical thought, to determine whether your actions are appropriate for the care of your patient.
The nursing process is a decision-making framework used to determine the needs of a
patient and to resolve how to care for them. The five steps of the nursing process are assessment,
diagnosis, planning, implementation, and evaluation. Registered nurses (RNs) participate in
all aspects of the nursing process, whereas licensed practical nurses (LPNs) or licensed
vocational nurses (LVNs) contribute to assessment and diagnosis, and participate in planning,
intervention, and evaluation.
Assessment is the gathering of information through signs and symptoms, patient history,
and objective findings. As a nurse, you can collect both objective and subjective data through
interviewing, physical assessment, and review of laboratory and diagnostic tests.
Diagnosis is using the assessment information to formulate nursing diagnoses, which are
statements describing problems that patients are experiencing. These diagnoses are prioritized
using Maslow’s hierarchy of human needs. Keep in mind that physiological or survival needs
must be met before other needs are of concern to the patient. Nursing diagnoses may be one-,
two-, or three-part statements. All diagnoses contain a diagnostic label. Two-part statements also
contain an etiology, and three-part statements contain an etiology plus defining characteristics
