BNS Section 2: Nursing Process and Clinical Judgment

Section Overview

The nursing process and the NCSBN Clinical Judgment Measurement Model (CJMM) are the two most important conceptual frameworks in contemporary nursing practice. Together they give nurses a structured, evidence-based approach to thinking about patients, organizing clinical data, formulating care priorities, acting safely, and continuously evaluating outcomes. Every skill introduced in the Basic Nursing Skills course is performed within these frameworks — they are not abstractions but practical tools that guide every patient encounter.

This section covers both frameworks in depth, examines how they relate to one another, and prepares students to apply them in the context of NCLEX-NG clinical judgment questions and real clinical simulation scenarios.

Learning Objectives

By the end of this section, students will be able to:

Describe each of the five phases of the nursing process (ADPIE) and explain how they guide individualized patient care. (Bloom’s: Understand)
Distinguish between medical diagnoses and nursing diagnoses using NANDA-I taxonomy. (Bloom’s: Analyze)
Construct a correctly formatted three-part nursing diagnostic statement (PES format). (Bloom’s: Create)
Identify the six cognitive skills of the NCSBN Clinical Judgment Measurement Model and apply them to a patient scenario. (Bloom’s: Apply)
Differentiate the NCSBN CJMM from the traditional nursing process and explain how they complement each other. (Bloom’s: Analyze)
Develop a prioritized plan of care with measurable, patient-centered outcomes and evidence-based interventions. (Bloom’s: Create)

The Nursing Process — ADPIE

The nursing process is a systematic, cyclical, and evidence-based framework that nurses use to identify patient problems, plan individualized care, implement interventions, and evaluate outcomes. It consists of five interrelated phases known by the acronym ADPIE.

Phase 1: Assessment

Assessment is the first and most foundational phase. The nurse collects subjective data (what the patient reports) and objective data (what the nurse observes and measures) through health history interviews, physical examination, vital signs, review of laboratory and diagnostic results, and review of the medical record.

Assessment is ongoing — not a one-time event at admission. Changes in patient status require immediate reassessment and modification of the care plan.

Phase 2: Diagnosis

Using the data gathered during assessment, the nurse identifies nursing diagnoses — clinical judgments about actual or potential human responses to health conditions. Nursing diagnoses differ from medical diagnoses in that they focus on the patient’s response to illness rather than the disease itself.

NANDA-I Taxonomy is the standardized language used for nursing diagnosis. A correctly written nursing diagnostic statement uses the PES format:

P — Problem: The nursing diagnosis label (e.g., Acute Pain, Impaired Gas Exchange, Risk for Falls)
E — Etiology: The related factor(s); what is contributing to the problem (“related to…”)
S — Signs and Symptoms: The defining characteristics that serve as evidence (“as evidenced by…”)

Example: Acute Pain related to surgical incision as evidenced by patient rating pain 8/10 and guarding behavior.

Note that Risk diagnoses (potential problems that have not yet occurred) use only two parts (P + E); there are no defining characteristics because the problem does not yet exist.

Phase 3: Planning

During planning, the nurse establishes patient-centered outcomes (goals) and selects evidence-based nursing interventions to achieve them. Outcomes must be:

Specific — clearly stated and focused on observable patient behavior
Measurable — include a scale or observable indicator (e.g., “pain ≤ 3/10”)
Attainable — realistic given the patient’s condition and resources
Relevant — directly address the nursing diagnosis
Time-bound — specify a timeframe (e.g., “within 30 minutes of intervention”)

Interventions are classified as independent (within nursing scope of practice), dependent (require a provider order), or collaborative (interprofessional).

Phase 4: Implementation

Implementation is the action phase in which the nurse carries out the planned interventions, delegates appropriately, and documents all care provided. Safety, patient dignity, and informed consent underpin every action. Real-time reassessment occurs continuously throughout implementation.

Phase 5: Evaluation

Evaluation determines whether patient outcomes have been met. The nurse compares the patient’s current status against the measurable outcomes established in the planning phase and decides whether to:

Continue the plan (outcomes partially met; interventions effective)
Modify the plan (outcomes not met; different interventions needed)
Discontinue the plan (outcomes fully met; problem resolved)

Evaluation feeds directly back into reassessment, making the nursing process a continuous, dynamic cycle rather than a linear sequence.

NCLEX-Style Practice Questions:

A nurse documents: “Impaired Physical Mobility related to left-sided hemiparesis as evidenced by inability to reposition independently.” Which component represents the etiology?
- A) Impaired Physical Mobility
- B) Left-sided hemiparesis ✓
- C) Inability to reposition independently
- D) The entire three-part statement
A patient’s outcome states: “Patient will ambulate 50 feet with a walker by end of shift.” After the shift, the patient ambulated 20 feet. Which is the nurse’s best action?
- A) Discontinue the nursing diagnosis — partial success is acceptable
- B) Document that the outcome was fully met
- C) Modify the plan to include physical therapy consultation and progressive ambulation goals ✓
- D) Transfer care of the mobility problem to physical therapy

The NCSBN Clinical Judgment Measurement Model (CJMM)

The NCSBN CJMM was developed to describe how experienced nurses think through complex clinical situations. It underpins the Next Generation NCLEX (NGN) examination format and reflects contemporary understanding of clinical reasoning. Where the nursing process provides a procedural scaffold, the CJMM provides a cognitive scaffold — describing the mental operations that expert nurses perform at each step.

The Six Cognitive Skills

Cognitive Skill	What the Nurse Does	Clinical Example
Recognize Cues	Identifies relevant data from the clinical situation and separates it from irrelevant background information	Noting that a postoperative patient’s SpO₂ has dropped to 88%, urine output has decreased, and they are increasingly restless
Analyze Cues	Interprets the meaning and significance of recognized cues; links findings to underlying pathophysiology	Determining that the above cues together suggest possible internal hemorrhage and hemodynamic compromise
Prioritize Hypotheses	Ranks possible explanations for the cues from most to least urgent or likely	Ranking hypovolemic shock above atelectasis as the priority hypothesis given the constellation of findings
Generate Solutions	Identifies nursing actions or provider interventions that address each prioritized hypothesis	Planning IV fluid bolus, notifying provider, increasing O₂, preparing for possible return to OR
Take Action	Implements the most appropriate interventions in the correct sequence	Elevating legs, increasing IV rate per protocol, applying supplemental O₂, calling provider using SBAR
Evaluate Outcomes	Determines whether the actions taken were effective by comparing current patient status to expected outcomes	SpO₂ improves to 94%, HR decreases from 118 to 96, patient reports feeling less anxious

Relationship Between the CJMM and the Nursing Process

The CJMM and nursing process are complementary, not competing, frameworks. The nursing process describes what nurses do in sequence; the CJMM describes how nurses think at each step. Together they form a complete picture of professional nursing practice:

Nursing Process Phase	Corresponding CJMM Cognitive Skills
Assessment	Recognize Cues
Diagnosis	Analyze Cues, Prioritize Hypotheses
Planning	Generate Solutions
Implementation	Take Action
Evaluation	Evaluate Outcomes

Contextual Factors That Influence Clinical Judgment

The CJMM acknowledges that clinical judgment does not occur in a vacuum. Three layers of context shape how nurses recognize and respond to clinical situations:

Environmental factors: Staffing levels, available resources, interruptions, unit culture, time pressure
Individual nurse factors: Experience level, knowledge base, fatigue, cognitive load, implicit bias
Client and clinical context: Patient complexity, language barriers, cultural factors, acuity of the situation

Understanding these contextual layers helps nurses identify when they may be at risk for judgment errors and implement strategies (e.g., structured handoffs, checklists, peer consultation) to mitigate that risk.

NCLEX-Style Practice Questions:

A nurse notes that a patient’s blood pressure has dropped from 132/78 to 90/54 mmHg over the past two hours. The patient is diaphoretic and reports feeling “dizzy.” Using the CJMM, which cognitive skill is the nurse employing when determining this change likely represents early hypovolemic shock?
- A) Recognize Cues
- B) Analyze Cues ✓
- C) Generate Solutions
- D) Evaluate Outcomes
After implementing interventions for a patient in hypovolemic shock, the nurse reassesses and finds the BP is now 116/74 mmHg, HR 88 bpm, and the patient is alert and oriented. Which CJMM cognitive skill does this reassessment represent?
- A) Prioritize Hypotheses
- B) Take Action
- C) Recognize Cues
- D) Evaluate Outcomes ✓

Care Planning in Practice

Prioritizing Nursing Diagnoses

When a patient has multiple nursing diagnoses, the nurse must prioritize them to ensure the most urgent needs are addressed first. The most widely used framework is Maslow’s Hierarchy of Needs, which places physiological needs (airway, breathing, circulation, nutrition, elimination) above safety, belonging, esteem, and self-actualization needs.

Priority Rules:

Life-threatening problems first — airway compromise, hemorrhage, severe hypoxia, cardiac instability
Actual problems before risk problems — a current impairment takes precedence over a potential one
Patient-identified concerns are valid priorities — what matters to the patient matters to care quality

Interprofessional Collaboration in Care Planning

The plan of care does not belong to nursing alone. BSN-prepared nurses are expected to participate actively in interprofessional rounds, communicate clinical concerns clearly using SBAR, and incorporate the goals and expertise of physicians, pharmacists, respiratory therapists, physical therapists, social workers, and others into a unified, patient-centered plan.

Standards Alignment

This section supports the following professional and regulatory frameworks:

AACN Essentials D1, D2, D3, D6: Knowledge for nursing practice; person-centered care; interprofessional partnerships
NCLEX-NG CJMM: All six cognitive skills (RC, AC, PH, GS, TA, EO)
QSEN: Patient-Centered Care (PCC), Evidence-Based Practice (EBP), Quality Improvement (QI), Safety (S)
CCNE Standards I, II, III: Professional identity, curriculum outcomes, and clinical competency
ACEN Standards 3, 4: Student outcomes and curriculum alignment