Chapter 33 Introduction to the Nursing Process

Nursing Care A primary goal of nursing To help individuals meet their basic and higher-level needs Nurses provide care to clients by combining scientific problem-solving methods with critical thinking skills to provide care through the nursing process.

Problem-Solving Problem-solving The basic skill of identifying a problem and taking steps to resolve it Trial-and-error problem-solving An experimental approach Experimenter does not have sufficient information to anticipate results. Scientific problem-solving

Scientific Problem-Solving Seven steps: Identify the problem. Gather information relative to the problem. Formulate hypotheses; choose preferred solution. Plan action to test suggested solution. Experiment and observe the results. Draw conclusions; understand what the results mean. Evaluate the solution.

Question Is the following statement true or false? Trial-and-error experimentation can be done only with the permission and understanding of the individual involved.

Answer True Trial and error must be used carefully when working with people because of the possible harmful results. Researchers develop strict guidelines to protect the safety and well-being of individuals and proceed with experimentation only with the permission of the individual involved.

Critical Thinking A complicated mix of inquiry, knowledge, intuition, logic, experience, and common sense is called critical thinking. It enables you to grasp the meaning of multiple clues and to find quick answers when facing difficult problems. It is an important nursing strategy for problem- solving.

Critical Thinking and Problem-Solving Critical thinking has some characteristics that are important for solving problems in healthcare. Examine facts and compare these facts with information already available, thereby being actively curious and critiquing ideas for reasonableness. Form own beliefs or ideas rather than accepting the thoughts or ideas of others and become an open- minded person, flexible to alternatives.

The Nursing Process The nursing process is a framework of scientific problem- solving combined with critical thinking skills. It directs the nurse and client as they together: Determine the need for nursing care Plan and implement the care Evaluate the results Nursing care plan (NCP) Guidelines derived on the basis of the nursing process to ensure consistency among nursing staff.

The Nursing Process

Question Is the following statement true or false? The nursing process highlights the differences in roles between licensed personnel and nonlicensed personnel.

Answer True The nursing process not only includes the actions involved in tasks but also integrates critical thinking. Unlicensed personnel are required to know how to take vital signs. In addition to how, the licensed nurse must also know why the vital signs are important and what is the relationship of the numbers obtained with the condition of the client.

Nursing Assessment The systematic and continuous collection of data Identify priorities Collect data Update database

Nursing Diagnosis The statement (or label) of the client’s actual or potential problem Recognize and label significant data. Recognize patterns or clusters. Identify strengths and problems. Reach conclusions. Validate observations. Write diagnostic statements.

Planning Development of goals for care and possible activities to meet them Identify priorities. Establish expected outcomes or goals. Anticipate nursing interventions. Prepare to document specific actions that will reach outcomes/goals by stating specific timeline for the plan.

Implementation The giving of actual nursing care Take actions that are necessary to achieve goals. Adjust actions as conditions change. Monitor and report results of assessment, goals, and interventions to other healthcare team members.

Evaluation The measurement of the effectiveness of nursing care Analyze the client’s responses to the problem, goals, and actions. Identify factors that contributed to success or failure of the NCP’s outcomes or goals. Re-evaluate and reassess. Continue with nursing process in a cyclic manner.

Question Which step of the nursing process allows the nurse to identify priorities and collect data? a. Nursing assessment b. Nursing diagnosis c. Planning d. Implementation e. Evaluation

Answer a. Nursing assessment The nurse identifies priorities, collects data, and updates database during the assessment phase of the nursing process.

Characteristics of the Nursing Process Systematic The nurse follows specific, orderly, and logical steps based on the client’s most important and often most vital needs; prioritization or prioritizing. Client-oriented Client needs are identified. Focus on meeting individualized client needs, rather than on performing specific skills.

Characteristics of the Nursing Process (cont’d) Goal-oriented: Goals, objectives, or expected outcomes are established as an early part of the nursing process. Short-term goals Measurable outcomes that can be achieved in hours, days, or weeks, depending on the individual problem Long-term goals Provide guidance for the days, weeks, or months during and after the time a client is seen by a health provider

Characteristics of the Nursing Process (cont’d) Continuous Because the life and health of individuals change, reassessment of the client’s needs is done frequently. The existing nursing process must be redesigned spontaneously to fit the most current and highest priority needs. Dynamic Although it contains definite steps, these steps often overlap; ever-changing.

Question Is the following statement true or false? The nursing process happens in a perfect sequence.

Answer False The nursing process is dynamic and ever-changing. Although it contains definite steps, these steps often overlap. Sometimes, they all occur at once.

Nursing Process and Quality Care The nursing process is an important tool for providing measurable and observable evidence indicating the effectiveness of nursing care given in any setting. Licensed nurses are responsible, or accountable, for their actions. Because all the nurses providing care for a client refer to the same care plan, consistency of care is ensured. If goals are not being met, a re-evaluation will indicate what further needs must be identified.

End of Presentation