Chapter 6 Nursing Process and Critical Thinking Jeanelle F. Jimenez RN, BSN, CCRN Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.

Introduction Nursing defined Nursing process Organizational framework for the practice of nursing Problem solving Six phases per the ANA or a modified 5 phases (ADPIE)

Relationships among the steps of the nursing process. Figure 6-1 (Modified from Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Relationships among the steps of the nursing process.

Assessment AKA “Data Collection” for the LVN/LPN A systematic, dynamic process by which the nurse, through interaction with the patient, significant other, and health care providers, collects information and analyzes data about the patient Subjective vs. Objective Data

Sources of Data Primary Source Secondary Sources Patient Most accurate Family members, significant other, medical records, diagnostic procedures, and nursing literature When the patient is unable to supply information, secondary sources are used

Methods of Data Collection Interview Biographical data Reason patient is seeking health care History of present illness Past health history Environmental history Psychosocial history Physical Exam Head-to-toe format

Diagnosing American Nurses Association defines as “A clinical judgment about the patient’s response to actual or potential health conditions or needs. Diagnoses provide the basis for determination of a plan of care to achieve expected outcomes.” The RN is responsible for formulating a nursing diagnosis. The LPN or RN may both observe and collect data.

Diagnosing Nursing Diagnosis North American Nursing Diagnosis Association International (NANDA-I) The nursing diagnosis is an identification of a health problem stated by utilization of the approved NANDA format.

Diagnosing Constructing a Nursing Diagnosis May be a 2-part or 3-part nursing diagnosis Select a nursing diagnosis label from the NANDA list List the contributing, etiologic, or related facts The specific cues, sings, and symptoms from the patient’s assessment

Planning The nurse establishes priorities of care, writes desired patient outcomes, selects and converts nursing interventions into nursing orders, and communicates the plan of care. Nurse must decide what can be done to lessen or solve an actual problem or prevent a risk problem from becoming an actual problem. The nurse decides what interventions will be effective.

Planning Priority Setting Nursing diagnoses are ranked in order of importance for the patient’s life and health. Physiologic needs come before safety and security. Safety and security needs come before love and belonging needs. Life-threatening and health-threatening problems are ranked before other types of problems. Actual problems may be ranked before risk problems. Priorities change as the patient progresses in the hospitalization; as some problems are resolved, new ones can be addressed.

Planning Establishing Desired Patient Outcomes The nurse predicts the condition of the patient following nursing interventions. This prediction is expressed in a statement that indicates the degree of wellness desired, expected, or possible for the patient to achieve. Outcome: A statement provides a description of the specific, measurable behavior that the patient will be able to exhibit in a given time frame following the intervention. Goal: A statement about the purpose to which an effort is directed.

Planning A Well-Written Patient-Centered Goal/Desired Outcome Statement Achieves the Following: Uses the word “patient” as the subject of the statement Uses a measurable verb Is specific for the patient and the patient’s problem Is realistic for the patient and the patient’s problem Includes a time frame for patient reevaluation Interventions may be done/developed by the nurse or ordered by the physician

Implementation Phase of the nursing process in which the established plan is put into action to promote achievement of the outcome. This phase includes ongoing activities of data collection, prioritization, performance of nursing interventions, and documentation. Both nurse- and physician-prescribed therapy are included. Documentation is a vital component of the implementation phase. “If it was not charted, it was not done” is a constant principle of nursing.

Evaluation A determination is made about the extent to which the established outcomes have been achieved. Review the patient-centered goals/desired patient outcomes that were established in the planning phase. Reassess the patient to gather data indicating the patient’s actual response to the nursing intervention. Compare the actual outcome with the desired outcome and make a critical judgment about whether the patient-centered goals/desired patient outcome was achieved.

Evaluation The nurse should make one of three judgments or decisions The outcome was achieved. The outcome was not achieved. The outcome was partially achieved. The plan of care is changed during this phase of the nursing process. Modifications can be made if the outcome has been achieved, partially achieved, or not achieved.

NANDA, NIC, NOC The NANDA-I Has Formed a Relationship With Two Other Groups. Nursing Intervention Classification (NIC) is a research group working at the University of Iowa to standardize the language used to organize and describe interventions. Nursing Sensitive Outcome Classification (NOC) is a research group working at the University of Iowa who have developed a standardized system to name and measure the results of patient outcomes. NANDA-I, NIC, and NOC are working together to standardize the language of nursing.

Role of the Licensed Practical/Vocational Nurse The nursing process may vary from state to state; review the state’s nurse practice act. Provide direct bedside nursing care. This direct care position allows the LPN/LVN to closely observe, prioritize, intervene, and evaluate the care provided to and for the patient.

Role of the Licensed Practical/Vocational Nurse Role of the Licensed Practical/Vocational Nurse in the Nursing Process Assessment Observe and report significant cues to the charge nurse or physician. Diagnosis Assist with the determination of accurate nursing diagnoses. Gather data to confirm or eliminate problems.

Role of the Licensed Practical/Vocational Nurse Role of the Licensed Practical/Vocational Nurse in the Nursing Process Planning Assist with setting priorities. Suggest interventions. Assist with the development of realistic patient-centered desired patient outcomes. Implementation Assist with the establishment of priorities. Carry out physician and nursing orders. Evaluate the effectiveness of nursing activities.

Role of the Licensed Practical/Vocational Nurse Role of the Licensed Practical/Vocational Nurse in the Nursing Process Evaluation Assist with reevaluation of the patient’s health state after nursing interventions. Suggest alternative nursing interventions when necessary.

Nursing Diagnosis and Clinical Pathways Managed Care A health care system whose aim is to enhance specific clinical and financial outcomes within a specific time frame Case Management A certified nursing specialty; refers to the assignment of a health care provider to a patient so that the care of that patient is overseen by one individual Assists the patient and family to receive required services, coordinates these services, and evaluates the adequacy of these services

Nursing Diagnosis and Clinical Pathways Multidisciplinary plan that schedules clinical intervention over an anticipated time frame for high-risk, high-volume, high-cost types of cases Includes such elements as diagnostic tests, treatments, activities, medications, consultations, education, daily outcomes, and discharge planning Variance Patient does not achieve the projected outcome

Critical Thinking Critical thinkers think with a purpose. They question information, conclusions, and points of view. They are logical and fair in their thinking. Critical thinking is a complex process, and no single simple definition explains all of the aspects of critical thinking. The nurse must be able to not only perform skills but also think about what he or she is doing. Nurses use a knowledge base to make decisions, generate new ideas, and solve problems.

Critical Thinking Characteristics of Critical Thinkers Reflect or think about what is being learned. Look for relationships between concepts or ideas. Analyze or critique behaviors. Make self-correction. Realize they do not know everything. Involve creative thinking.

Critical Thinking Individuals Can Become Better Critical Thinkers Verbalize thoughts aloud. Hear others think aloud to help learn how other people reason. Study to gain specific theoretical knowledge; ask other people to evaluate their thinking; and use mistakes to learn.

Evidence-Based Practice Research versus educational knowledge, consultation with peers, and own experience