Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 1 Overview of Nursing Process, Clinical Reasoning, and Nursing Practice Today

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Nursing process is a linear process.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Rationale: The nursing process is a cycle rather than a linear process.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process Foundation for clinical reasoning Required by national practice standards Tested on NCLEX First tool “to think like a nurse”

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process (cont.) Cycle Not a linear process Purposeful

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question What are the phases of the nursing process? –1. Assessment –2. Diagnosis –3. Planning –4. Implementation –5. Evaluation A. 1, 2, and 4 B. 1, 3, 4, and 5 C. 1, 2, 3, and 4 D. 1, 2, 3, 4, and 5

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer D. 1, 2, 3, 4, and 5 Rationale: The five phases of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Phases in Nursing Process Assessment Diagnosis Planning Implementation Evaluation

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Collect and record all the information to: –Predict, detect, prevent, and manage actual and potential health problems –Promote optimum health, independence, and well- being –Clarify expected outcomes (results)

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Diagnosis Analyze the data you gathered, draw conclusion, and determine whether there are: –Risks for safety or infection transmission (deal with these immediately) –Signs or symptoms that need evaluation by a more qualified professional (report these immediately) –Actual and potential health problems requiring nursing or medical management

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Diagnosis (cont.) Risk factors requiring nursing or medical management Issues that aren’t quite clear, but require further investigation Learning needs that must be addressed Patient resources, strengths, and use of healthy behaviors Health states that are satisfactory but could be improved

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Planning Clarify expected outcomes (results), set priorities, and determine interventions (nursing actions). The interventions are designed to: –Detect, prevent, and manage health problems and risk factors –Promote optimum function, independence, and sense of well-being –Achieve the expected outcomes safely and efficiently

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Implementation Put the plan into action. –Assess the patient to determine current status— decide whether the patient is ready and the interventions are still appropriate. –Perform the interventions (nursing actions). –Reassess the patient to determine end results (outcomes). –Make immediate changes as needed. –Chart nursing actions and patient responses.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Evaluation Do a comprehensive patient assessment to decide whether expected outcomes have been met or whether new problems have emerged. –Decide whether to modify or terminate the plan. –Plan for ongoing continuous assessment and improvement.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Keys Things to Remember Nursing process phases –Overlap –Interrelated

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Accuracy of Nursing Process Steps Good communication skills Factual Relevant Comprehensive assessment data

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process and Nursing Activities Formal care planning Documentation Guide for thinking at the point of care every day

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Critical thinking is a broad term that includes clinical reasoning.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True Rationale: The terms critical thinking and clinical reasoning are often used interchangeably. Critical thinking is a broad term that includes clinical reasoning.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Critical Thinking and Clinical Reasoning Often used interchangeably Critical thinking is a broad term that includes clinical reasoning.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Reasoning Specific term Assessment and management of patient problems at the point of care

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Critical Thinking Promoting teamwork and streamlining work flow Reasoning other issues, besides assessment, and management of patient problems

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Complements Other Health Care Workers Focusing on both medical problems and on the impact of medical problems and treatment plans on patients’ lives Aims to promote health –Maximizing independence –Sense of well-being –Ability to function regardless of presence of illness or disability

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Application of Nursing Process Requires application –National and state laws –Local policies and procedures Follows ethics codes and principles. Applies a code of conduct.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Competent in the Use of Nursing Process Develop critical thinking behaviors Strong interpersonal and technical skills Be willing and able to care