Presentation on theme: "The Nursing Process and Critical Thinking"— Presentation transcript:
1The Nursing Process and Critical Thinking Chapter 12The Nursing Process and Critical Thinking
2Learning Objectives Describe the components of the nursing process. Explain the role of the LPN/LVN in the nursing process.Describe the proper documentation of the nursing process.Describe the relationship between the nursing process and the process of documentation.Explain the relationship between the nursing process and critical thinking.Describe the characteristics of a critical thinker.Describe how critical thinking skills are used in clinical practice.Describe principles of setting priorities for nursing care.
3AssessmentInvolves collecting data about the health status of the patientA registered nurse must perform the initial admission assessment for each patientThe LVN/LPN collects data through surveillance and monitoring and performs focused nursing assessmentsA focused nursing assessment is defined as “an appraisal of the client’s status and situation at hand that contributes to ongoing data collection.”What does the word data mean?
4Assessment Subjective data Objective data Information reported by patient and family in a health history in response to direct questioning or in spontaneous statementsObjective dataInformation that nurse or other members of health care team obtain through observation, physical examination, or diagnostic testingSubjective data usually are documented in the patient’s own words and include information such as previous experiences and sensations or emotions that only the patient can describe.Objective data can be seen or measured (e.g., heart rate, wound condition, and laboratory values).What are sources of subjective data and objective data?
5Physical Examination Inspection Purposeful observation of the person as a whole and then systematically from head to toeWhen does inspection of the patient begin?
7Physical Examination Palpation Uses touch to assess various parts of the body and helps to confirm findings that are noted on inspectionThe hands, especially the fingertips, are used to assess skin texture, moisture, and temperature or the presence of swelling, lumps, masses, tenderness, or pain.What is one thing you should do before palpating the patient?When examining the abdomen, palpation should be light at first for surface characteristics and then deeper for abdominal contents.
9Physical Examination Percussion Tapping on the skin to assess the underlying tissuesWhat are the most common areas for percussion?Short, sharp strokes elicit sounds and subtle vibrations that are characteristic of underlying organs and certain conditions.To percuss:Place one hand flat on the skin over the area to be assessed.Use the tip of the middle finger of your other hand to lightly tap the middle finger of the hand that rests on the patient.Tap two times just behind the nail bed before moving to the next area.
14Nursing Diagnosis Derived from data gathered during the assessment Nursing diagnosis different from medical diagnosisFocuses on the patient’s physical, psychological, and social responses to a health problem or potential health problemThe RN formulates nursing diagnoses; the LVN/LPN is expected to assist with identifying patient needs and implementing plan of careNursing diagnoses provide a basis for planning nursing interventions that can help prevent, minimize, or alleviate the problem.What is a medical diagnosis?
15Nursing DiagnosisNorth American Nursing Diagnosis Association (NANDA International)Develops and revises nursing diagnosesTable 12-1: list of accepted nursing diagnosesWritten in a PES formatP = problemE = etiology or cause of the problemS = signs and symptoms of the problemThe PES format helps make the general nursing diagnosis fit a specific patient care problem.What is an example of a nursing diagnosis?
16PlanningDevelop a nursing care plan for the patient based on nursing diagnosesNursing care plans a form of communication with other health care professionals to ensure continuity of care, prevent complications, and provide for health teaching and discharge planningWho is responsible for initiating the plan of care?
17Planning Steps in planning nursing care Determine priorities from the list of nursing diagnosesSet long-term and short-term goals to determine outcomes of careDevelop objectives to reach the goalsWrite nursing orders to direct care to meet the goalsPriorities established according to the most immediate needs of the patientWhat are the steps in planning nursing care usually based on?Goals should be stated in terms of patient outcomes.Nursing orders are the actions or interventions prescribed to help achieve the stated goals and objectives.
18Intervention (Implementation) Actual performance of the nursing interventions in the plan of careIncludes direct patient care, health teaching, or carrying out ordered medical treatments such as medications or dressing changesNurses provide care to achieve established goals of care and then communicate the nursing interventions by documentation and reportThe care plan must be flexible and reflect changes in the patient’s health care needs
19EvaluationOngoing process that enables you to determine what progress the patient has made in meeting the goals for careThe outcome criteria provide objective measures for determining the effects of careOutcomes compared with expected outcomes of patient care to determine whether the goals have been met, partially met, or not metThe plan of care should be reexamined and modified where necessary.How can the results of an ongoing evaluation be used?
20EvaluationImportant in individual care, but also provides data on quality of care in health care institutionQuality assurance audits conducted by health care agencies as well as Joint Commission on Accreditation of Healthcare OrganizationsAmerican Nurses Association Standards of Care used to determine if nurses have carried out the nursing process as documented in patient recordsAreas evaluated by The Joint Commission include the standards of nursing care used, the quality and effectiveness of nursing care, and the organization of the patient care system.How are nursing audits conducted?
21Clinical PathwaysStandard care plans developed to set daily care priorities, schedule achievement of outcomes, and reduce length of hospital staysInclude patient outcomes and timelines for the sequence of interventionsClinical pathways: collaborative and comprehensive; jointly developed by all members of health care team; and cover many aspects of care, not just nursing interventionsWhat are the benefits of clinical pathways?There are concerns about the potential for legal liability when there are deviations from pathways (even when justified).
22Concept MapsVisual plans of care that illustrate the relationships between and among pathophysiology, signs and symptoms, nursing diagnoses, and collaborative interventionsUsed primarily as learning tools to develop comprehensive plans of care
23Nursing Documentation Helps achieve continuity of care because it provides for communication among caregivers; a record of patient’s progressProvides a legal record of care provided and a means to verify services rendered for insurance paymentsPatient assessments and observations and all nursing interventions should be charted as a permanent part of the patient’s medical record, which is a legal record.
24Nursing Documentation All treatments and care, including medicationsProcedures performed at the bedside, on the unit, or inside or outside the facilityPatient’s reaction to proceduresObservations of the patient
25Nursing Documentation Subjective and objective signs and symptoms experienced by the patientEvidence of changes in the patient’s physical, psychosocial, and spiritual needs and statusAny unusual incidents, such as falls or injuries, that occur during the patient’s stay in the health care facility
26Nursing Documentation Should be factual, current, complete, organized, and accurateWriting should be legible, using proper grammar, punctuation, and spellingObservations stated objectively, describing only what was seen, heard, felt, or smelledDirect quotations from the patient regarding symptoms are appropriateWith paper charts, each page should have the patient’s name, and the date and time should be noted for each entry.When should documentation be done?
27Nursing Documentation Each time an entry is made, sign with your full name and titleUse only permanent ink, and make no erasuresIf you make an error in charting, cross out the entry and write “error” or “mistaken entry,” followed by your initialsIncreasingly, patient records are entered and maintained in computerized charting systems.Some systems allow documentation at the patient’s bedside.What are the advantages and disadvantages of computerized charting?
28Documentation Formats Nurses’ notesPages of narrative recordings containing assessment data, interventions carried out by the nurse, and evaluation data collectedFlow sheetsMay be graphs of vital signs or tables in which nurses may check or initial boxes indicating activities or care providedWhat are some examples of charting approaches?
29Documentation Formats Problem-oriented medical record (POMR)Record keeping that focuses on patient problems rather than on medical diagnosesExcellent means of communication among the various disciplines that are providing careThe charting is done in a SOAPIER formatS—Subjective; O—Objective; A—Assessment;P—Plan; E—Evaluation; R—RevisionEach health care provider involved in the care of the patient charts on the same progress notes in the same format.What information provides a foundation for problems formulated in the POMR?
30Critical ThinkingDefined as “reflective and reasonable thinking that is focused on deciding what to believe or do”Tools to seek and apply knowledgeNursing deals with people in states of change in an environment that is constantly evolving; critical thinking skills allow the nurse to base the plan of care on actual patient data.How can critical thinking skills be applied to nursing care?
31Relationship of Critical Thinking to the Nursing Process The nursing process is a framework for developing, implementing, and evaluating a plan of careIt spells out the patient’s needs and problems, the goals for care, interventions to achieve goals, and how goal achievement will be assessed
32Relationship of Critical Thinking to the Nursing Process The nursing process does not flow smoothly from one step to the next, but often moves back and forth between stepsThe nursing process is a sequence of steps that should be based on critical thinkingWhy should “ready-made” care plans not be used?
33Characteristics of a Critical Thinker CuriosityThe desire, not just to know, but to understand how and why, to apply knowledgeSystematic thinkingUses an organized approach to problem solving, rather than knee-jerk responsesAnalyticApplies knowledge from various disciplines, approaches a problem by examining the parts and seeing how they fit together
34Characteristics of a Critical Thinker Open-mindedWilling to consider various alternativesSelf-confidentSense of assurance that the problem-solving process produces a good conclusion/planMaturityRecognition that many variables are at work in patient situations, and sometimes the best plans do not workTruth-seekingEager to know, asking questions, seeking answers, reevaluates “common knowledge”
35Critical Thinking Tools InterpretationClarifying meaning of events, dataAnalysisExamining ideas, breaking down into componentsEvaluationAssessing possibilities, opinions, usual practices
36Critical Thinking Tools InferenceDeriving alternatives, drawing conclusionsExplanationPresenting arguments for views, decisions; justifyingSelf-regulationReconsidering conclusions, recognizing need to make changes