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CLINICAL DECISION MAKING & THE NURSING PROCESS

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Presentation on theme: "CLINICAL DECISION MAKING & THE NURSING PROCESS"— Presentation transcript:

1 CLINICAL DECISION MAKING & THE NURSING PROCESS
NRS 110

2 Critical Thinking Revisited
Knowledge Experience Reflection Intuition

3 Components of Critical Thinking in Nursing
Specific Knowledge Base Experience Critical Thinking Competencies Diagnostic Reasoning Clinical Decision Making Nursing Process Critical Thinking Attitudes Critical Thinking Standards Intellectual Standards Professional Standards

4 Clinical Decision Making
Critical thinking process for choosing the best actions to meet a desired goal To act or not to act, that is the question! Criteria used to make decisions Collaboration Problem Identification Who is responsible for making the decision?

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6 Level of Critical Thinking
Basic Complex Commitment

7 NURSING PROCESS Assessment Diagnosis Planning Implementation
Evaluation

8 The nursing process in action

9 Step One: Assessment Collect data (Types of data, Sources of data, Methods of data collection) Organize data Validate the data Record & report

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13 Step 2: Diagnosis Analysis of assessment data leads to problem identification NANDA list Types of nursing dx.

14 Anatomy of a Nursing Diagnosis
Problem (Diagnostic label) Etiology (Related factors and Risk factors) Defining Characteristics Differentiating Nursing Diagnoses from Medical Diagnoses Differentiating Nursing Diagnoses from Collaborative Problems

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17 The Diagnostic Process
Analyzing data: Compare data against standards, cluster data, identify gaps and inconsistencies in data Identify health problems, determine problems and risks, determine strengths

18 Formulating Diagnostic Statements

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21 Step 3: Planning Set priorities Apply standards
Identify goals & outcomes Select interventions Record the plan (nursing care plan)

22 What are the priorities?

23 Maslow’s Hierarchy of Basic Human Needs

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27 Guidelines for Writing Goal Statements
Write goals in terms of client responses Be sure the desired outcomes are realistic and compatible with ordered therapies Make sure that each goal is derived from only one nursing diagnosis Use observable, measurable terms for outcomes Involve the client in the process

28 CONCEPT MAP Ineffective Airway Clearance (Gas Exchange)

29 Step 4: Implementation Put your plan into action
Perform the interventions Note patient response to interventions Record & report

30 Types of Interventions
Independent (nurse initiated) Dependent (physician initiated) Collaborative

31 Step 5: Evaluation Did the plan work? Was goal achieved?
What was the outcome of the care provided. Stated in measurable terms. It’s all about outcomes!

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33 Case Scenario A.A. is an 28 y.o. female who was admitted with pneumonia. She presents with complaint of cold x 2 weeks, dyspnea on exertion, , orthopnea, decreased oral intake. Assessment of patient reveals: T 103F, P 92, R 22 shallow, BP 122/80 Dry mucous membranes, hot pale skin Decreased breath sounds, inspiratory crackles Ineffective cough-coughing up thick pink sputum Lethargic, c/o being weak

34 Now lets write the plan down!

35 Concept Map Steps Place your main issue/problem in the middle
Determine key problems/concepts that have a direct relationship to the main problem Add clinical data to appropriate problem boxes Draw lines between related problems. Label with a nursing diagnosis Identify goals/outcomes Add interventions Evaluate patient response to interventions

36 CONCEPT MAP Ineffective Airway Clearance (Gas Exchange)


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