Nursing Process: A tool for Critical thinking Flashcards
Student care plans - allows student process to understand how think like a nurse - framework for CT and clin judgement; take content learned and apply it to specific pat situations
Nursing student learns to to write and use nursing care plans to learn to “think like a nurse” (clinical reasoning and critical thinking)
Students learn to apply knowledge gained in classes to create plan of care for patients in clinical setting
Student learns scientific rationales for each intervention chosen because nurses are legally accountable for responses to interventions performed
As students build on knowledge and critical thinking, NP becomes second nature to provide quality care for each patient
Why do I need to know nursing process
Purposeful, goal-directed thinking based on scientific knowledge - knowledge extract from lectures
Involves viewing all the facts, seeking and weighing the alternatives, and selecting the best one to meet the desired outcome
Defining critical thinking
reflection/eval
language/communication
Thinking and learning
Intuition
Aspects of critical thinking (CT)
Review successes/opportunities for improvement/revision
Eval imp how intervention applied help/not help certain pt situation
reflection/eval
Be clear and accurate (verbal and written)
Esp N diagnosis allow for specific language can all use to understand what is happening with certain client
language/communication
Info mor powerful and able apply it
Interrelated and lifelong process
As knowledge base and experience grow, so does CT
Thinking and learning
Cognitive and emotional cues: “something is not right”
What info relevant and not
Intuition
Interpretation
Analysis
Inference
Eval
Explanation
Self-regulation
Critical thinking skills
Look for patterns to categorize data-clarify uncertain info
Interpretation
Make no assumptions
Be open to what data reveals - look heavily at data; fill in gaps
Analysis
Look at significance of findings; what probs exist
Inference
Use criteria to determine results - intervention successful or not
Eval
Support your findings and use knowledge to select strategies
Explanation
self-awareness of need to improve
Self-regulation
Decision making criteria
Answers assist nurse to:
Clinical decision making:
What needs to be achieved? - make progress
What info needs to be preserved?
What needs to be avoided? - want to prevent
What need do for pat
Decision making criteria
Make decisions and set priorities - help nurse
Select activities/interventions
Anticipates what may go wrong
Consider alternatives
Answers assist nurse to:
Lexicon - standard nursing language
North American Nursing Diagnosis Association (NANDA)
Nursing Intervention Classification (NIC)
Nursing Outcomes Classification (NOC)
Nursing process: standard nursing language
Diagnosis labels, definitions and defining characteristics
North American Nursing Diagnosis Association (NANDA)
Interventions/activities linked to NANDA
Nursing Intervention Classification (NIC)
Behaviors measured along a continuum in response to nursing interventions
Nursing Outcomes Classification (NOC)
A systematic, problem-solving process that is used to identify, diagnose, and treat human responses to health and illness
Nursing process defined
Nurse focus
Nurse wants to act upon manifestions (s&s)
Physician focus
A systematic, problem-solving process that is used to identify, diagnose, and treat human responses to health and illness
Patient’s responses to symptoms
Patient’s ability to care for self
Nurse focus
Disease process/pathology
Treatment of disease
Physician focus
Five inter-related steps (ADPIE)
Assessment:
Diagnosis;
Planning
Implementation:
Evaluation:
Not linear - more spiral
Steps of the NP
collect data; organize data
Assessment:
analyze data; identify nursing diagnoses and collaborative probs
Diagnosis;
(Outcome and Interventions/Activities): proriotize probs; identify measurable outcomes (goals); select nursing interventions; doc plan of care
Planning
carry out nursing orders; doc nursing care and client responses
Implementation:
monitor client outcomes; resolve, cont, revise current plan of care
Evaluation:
Accurate and comprehensive assessment leads to accurate nursing diagnosis
ASSESSMENT
Data collection
Nursing assessment
- Collect data - ongoing: come from pt; assessment; H&P
- Identify cues & make inferences: cues: pieces actually stick out that interesting to know
- Validate info: check info a diff way
- Organize (cluster data)
- Identify patterns
- Report and record
Lead to Nursing diagnosis
ASSESSMENT
Data sources
Methods
Subjective (aka symptoms)
Objective (are signs)
Data collection
Patient/Family - listen to pts since know their body
Health care team
Medical record - read H&P before meet pt so have good understanding what’s going on
Diagnostic and Lab data
Data sources
Interviews/History
Observations
Physical Assessment
Medical Record review
Methods
One type data
What a person states or communicates in writing
Subjective (aka symptoms)
One type data
Observations or measurements of a patient’s health status
Objective (are signs)
Cues
Inference
Identifying data
Identifying data which includes Information the nurse obtains through the use of the senses (S & O data)
Relevant data- decide what info. is meaningful/important
Cues
Process of deriving logical conclusions from multiple observations (inductive reasoning)
May be correct or incorrect, or correct to within a certain degree of accuracy; requires more data - find extra data that supports/not support inference making
Inference
complement and clarify the other
Subjective and objective may
objective - cues differ from subjective and objective; need have good look at pt
Subjective may differ from
Rule: Review your data and reflect. Be sure information is accurate, factual and complete.
Ask questions: What may be missing? abnormals? potential risks? Immediate needs?
Based on data make inferences
Data measured accurately can be accepted as factual (ht, wt, lab results, etc.)
Data that some one else observes may or may not be true. - make sure you believe data is true
Critical info should be checked
Validate data
Look for factors that may alter data - EX: renal pt elevated d-dimer/looking for clots (not looking at if pt has a clot but may be altering data r/t lab
Recheck your own data for accuracy
Ask someone else to collect same data/validate data
Double check that equipment is working appropriately - pts with afib do manual BP
Double check abnormal or inconsistent info.
Clarify statements and verify your inferences with pt - repeat what hear
Compare your impressions with other team members
Compare what patient states with observations for congruency
Guidelines to validating data
Identify patterns by organizing the cues into meaningful usable clusters
Data clusters
Organize data
set of signs and symptoms that are grouped together in a logical way; cluster relevant data
Data clusters
Analysis
Select a Nursing Diagnosis
Identify patterns/interpreting data
Recognize patterns/trends in clustered data - imp for AEB portion of N diagnosis statement; pop all inform together that proves what occurring to pt; look at clustered data
Compare to standards and textbook knowledge
Draw conclusions about the real problem
Analysis
Based on the defining characteristics of the prob
Select a Nursing Diagnosis
To clarify the exact nature of the problem
Potential risk factors
To achieve the overall expected outcome
Assessment - diagnosis - planning - intervention - evaluation: all connect together and spiral back on each other; need ensure have stuff can predict and prevent probs or promote wellness
Nursing diagnosis: Purpose
Clusters and patterns of data contain defining characteristics (manifestations: signs and symptoms) that support the Nursing Diagnosis
Nanda N. diagnosis also identifies potential Related Factors
Identifying nursing diagnosis
Functional, psychological, pharmacological, mechanical, physiological
Nanda N. diagnosis also identifies potential Related Factors
Actual
Potential (Risk for)
Wellness
Collaborative
Types of nursing diagnosis labels
A problem that has been validated by the presence of major defining characteristics
Actual
Individual is vulnerable to development of problem(s)
Potential (Risk for)
Assist individual to pursue optimal health
Wellness
Interdisciplinary plans of care
Hospitals use - holistic plans of care use all HCPs
Collaborative
*PES= problem etiology symptoms
Contains the Nursing problem/diagnosis (diagnostic label), etiology (contributing factors or cause: r/t), and manifestations: signs & symptoms (pt’s defining characteristics) of the diagnosis
Start with ABCs then work way down to other issues
Writing three part (actual) nursing diagnosis sentence
Risk for:
Two Part contain the label and a list of the individual risk factors
Risk for falls: lack of awareness of hazards; use of walker; narcotic pain medications
Problem not occurred: no signs/symptoms
Preventing potential for injury by controlling the risk factors
Writing two part: nursing diagnosis sentence
One part contain the label
More home based
Wellness nursing diagnosis
Patient has desire for higher level of wellness
Example: Patient who desires to improve nutrition habits to lose weight
Readiness for enhanced nutrition
Writing one part: nursing diagnosis sentence
Potential complications of medical conditions/prbs nurse cannot treat independently
Nurses manage collaborative problems using physician-prescribed intervention
Nurses monitor for risk, to detect onset of problems, or evaluate change in status/to see anything may go wrong/see pt is improving
Nurse having call physician to get order for pain med even if PRN; if was already on the MAR - independent and decision to give it
All collaborative problems begin with the diagnostic label “potential complication” (PC) Monitoring one problem
Potential Complication: hyperglycemia R/T long-term corticosteroid therapy
Collaborative probs
Problems will exist or progress without detection
Omitting interventions that are essential
Choose inappropriate interventions that may:
Waste time
Cause harm
Aggravate the real problem
Place yourself in legal jeopardy
Need do appropriate N diagnosis and prob
Risks of nursing diagnostic errors
Don’t make a medical diagnosis a nursing diagnosis: focus on person’s response to the medical problem; medical diagnosis cannot be beginning but can relate it to medical issue
Incorrect: Mastectomy r/t cancer
Correct: Risk for self-concept disturbance r/t effects of mastectomy
Errors in writing nursing diagnosis: making a nursing diagnosis from a medical
Don’t rename a medical problem to make it sound like a nursing diagnosis
Incorrect: Imbalanced Hemodynamics related to hypovolemia
Correct: Fluid volume deficit r/t hypovolemia
Errors in writing nursing diagnosis: renaming a medical prob
Incorrect: Risk for injury r/t lack of side rails on the bed
Correct: Risk of injury r/t disorientation and attempts to get out of bed
Errors in writing nursing diagnosis: legally incriminating
Don’t state two problems at the same time - can be related to 2+ issues and needs to be evidence of more than one issue but first part needs be one nursing issue; separate out
Incorrect: Pain and fear r/t diagnostic procedure
Correct: Fear related to unfamiliarity with diagnostic procedures; Pain r/t movement in during radiology exam
Errors in writing nursing diagnosis: two probs in one diagnostic statement
Don’t make a nursing diagnosis out of a physician’s order or a collaborative problem; monitor for potential complications; r/t can be medical diagnosis but not a physician’s order
Incorrect: Imbalanced nutrition related to being NPO (NPO is a physician’s order. Monitor potential complications)
Correct: Risk for dehydration r/t fluid imbalance
Errors in writing nursing diagnosis: creating a nursing diagnosis from a physician’s order
Don’t write a nursing diagnosis based on value judgments; r/t something happen not to beliefs
Incorrect: Spiritual Distress r/t atheism as evidenced by statements that she has never believed in God.
There may be no diagnosis in this situation. This person may be at peace with her beliefs (not with yours!)
Errors in writing nursing diagnosis: value judgements
The Plan of Care should be individualized to pat; may mean talk with pt to make mutually acceptable goals: ST and LT goals for pt
Consider age, health, culture, capabilities, human and financial resources
Partner with patient
Standards of care
Diagnosis - planning: priorities, outcome, interventions, activities
Planning
Chosen Goals/Outcomes guide the POC (plan of care) and choices for nursing interventions
Goals
Outcomes
Measuring stick for the Plan of Care
Use objective criterion for measuring goals
Goals and outcomes
Describe early expected benefits of nursing interventions
Goals
Standardized outcomes developed by nursing experts; describe benefits expected at a certain point in time
Outcomes
Describe something you can hear, see, feel, or smell in the person to demonstrate the outcome
Use objective criterion for measuring goals
SMART GOALS
Specific (individualize to patient)
Measurable (correct verb and indicators)
Attainable - can get it
Realistic oriented
Timed (expected completion)
Developing goals/outcomes
Identify
Describe
State
Verbalize
Demonstrate
Communicate
List
Hold
Exercise
Perform
Express
Relate
Walk
Cough
Share
Will lose
Will gain
Has an absence of
Measurable verbs for goals and outcome statements - help with SMART goal: things need to be able to see, smell, feel, hear
Actions performed by the nurse to:
Can be Independent (already on MAR) and Collaborative (call and get med)
Choices listed under each Nursing Diagnosis - look at handbook
interventions/activities
Reduce risks
Monitor health status
Resolve, prevent, or manage problems
Facilitate independence or assist with ADLs
Promote optimum sense of physical, psychological, and spiritual well being
Actions performed by the nurse to:
Factors to Consider
Priorities of care - ABCs; what effect pt most; damage
Acceptability (patient) of goal or end of interventions
Feasibility
Fit the Chosen Nursing Diagnosis
Expected goals/outcomes
Evidence-based nursing knowledge
Selecting interventions
- Take care of immediate life-threatening issues (ABC)
- Safety issues
- Patient-identified issues
- Nurse-identified priorities
Priotizing interventions
Based on the overall picture, the patient as a whole person, and availability of time and resources
- Nurse-identified priorities
Research evidence that supports successful intervention
Valid sources-textbooks, scientific websites, nursing journals, research studies, policy & procedures (in hospital - back up for safety), interdisciplinary journals, etc.
Scientific rationale: EBP
Helps nurse weigh risks and benefits of performing intervention
You are legally accountable for responses to interventions performed!
Research evidence that supports successful intervention
4 key questions need to be answered
Perform the chosen prioritized, evidence-based interventions in a …
Throughout entire plan of care all pieces must link together and be related to each other and must always be evaluated
Implementation: Putting the Plan into Action
Can be done to prevent/minimize risk/causes of prob
Can be done to manage prob
How tailor interventions to meet EO
How likely are we to get desired versus adverse responses to the intervention
4 key questions need to be answered
Safe, effective, organized way to get the results needed while preventing errors
To meet the goals and outcomes of the plan
Continually evaluate the effectiveness of each intervention and make revisions
Perform the chosen prioritized, evidence-based interventions in a …
Rule: Assuming your diagnoses are accurate and your outcomes and interventions are appropriate, the ultimate question to be answered during evaluation is:
Implementation - evaluation: Goals met? Partially met? Unmet? Continue the plan? Revise the plan?
If goal met: goes back into assessment phase where keep making sure not fall below line
Partially met: decide if continue/revise plan or may need more time which would be a revision and goes back to assessment
Unmet - revision of plan
Are the goals/outcomes criteria ….
Reflect on why goal/outcome was not met.
Review all the steps of the nursing process
Update the care plan
Always assess and evaluate
Evaluation
“Has the patient achieved the determined goals/outcomes?”
Rule: Assuming your diagnoses are accurate and your outcomes and interventions are appropriate, the ultimate question to be answered during evaluation is:
Completely met? How do you know?
Partially met? Can you revise the plan?
Not met at all? Why not?
Are the goals/outcomes criteria ….
What must be changed/revised in the POC to move the patient towards the intended outcome?
Reflect on why goal/outcome was not met.
Evaluation happens in every step of the nursing process - make sure what doing is appropriate and working for specific pat
Assessment: Perform assessment to detect changes in pt. health; confirm data
Diagnosis: Determine if all diagnoses that must be managed are listed in plan of care
Planning: Check that goals/outcomes and interventions are appropriate, prioritized, realistic, and measurable
Implementation: Determine if plan is being followed as prescribed and the factors that help or hinder the progress
Good evaluation examines all steps
Nursing Assessment data must support the diagnostic label and the related factors must support the etiology
The outcome and goals flow from the diagnosis
Specific interventions must be prioritized and move the patient towards achieving the goals/outcomes.
The evaluation restates the goals/outcome including the indicators of success or failure of the plan
Nursing care plan summary
