NURSING PROCESS
Nursing 100
LECTURE OUTLINE NOTES
Basic Nursing, A Critical Thinking Approach, 4th Edition, Potter &
Perry, 1998, Mosby
Chapters 4-9, 14
CRITICAL THINKING AND NURSING JUDGMENT
Chapter 4, pp. 65-79
Critical Decisions in Nursing Practice
Nurses are responsible for choosing the most effective
solution to the client's needs based on previous knowledge and experience,
client input, and the objective data collected.
Critical Thinking Defined
The active, organized, cognitive process used to carefully
examine one's thinking and the thinking of others. It involves the use of
the mind to form conclusions, make decisions, draw inferences, and
reflect. (See Table 4-1, p.66, Critical Thinking Skills Proposed by the
American Philosophical Association).
Reflection - thinking back on an event to find
meaning for the event. Can be useful in evaluating nursing actions and
outcomes for future planning. (See Box 4-1, p. 97, for Tips for
Facilitating Reflection).
Language - the nurse must be able to use language
precisely and clearly to communicate with clients, family, and other health
professionals.
Levels of Critical Thinking
Basic thinking accepts the thinking of the
experienced, expert for solution to problems. The complex thinker
considers viable options to the obvious solutions and the impact of those
options to meet the client needs. The third level, commitment, involves
independent problem solving and taking the responsibility for the decision and
the outcome.
Critical Thinking Competencies
General Critical Thinking
Scientific Method - An organized process of
observation and gathering facts (data) leading to a conclusion. (See
Table 4-2, p. 69, Steps of the Scientific Method)
Problem Solving - Identifying a problem/need and
applying the appropriate solution.
Decision Making - Using all information available and
considering the consequences to determine and act decisively.
Specific Critical Thinking
Diagnostic Reasoning and Clinical Inferences - The
nurse uses collected data to make a judgment about the client's problem and
then infers as to the client's progress.
Clinical Decision Making - Prioritizing and choosing
care options based on specific criteria. Can be used for individuals or
groups of clients. (See
Specific Critical Thinking in Nursing
The Nursing Process - the systematic, comprehensive
approach to nursing care.
Thinking and Learning
A Critical Thinking Model (See Figure 4-1, p. 71)
Specific Knowledge Base
Experience
Competencies (See Box 4-3, III, p. 72,
Components of Critical Thinking in Nursing)
Attitudes (See Box 4-3, IV, p. 72, and
Table 4-3, p. 73, Critical Thinking Attitudes and Applications in
Nursing Practice)
Standards for Critical Thinking (See Box 4-3, V
& VI, p. 72 and Box 4-4, p. 75, Examples of Evaluation Criteria)
Nursing Process Overview (See Figure 4-3, p. 75, Five-step nursing process model and Table 4-4, p. 76, Summary of Nursing Process)
Synthesis in Practice
Assessment
Synthesis - utilizing the components of critical
thinking
Nursing Diagnosis
Planning
Implementation
Evaluation
CRITICAL THINKING ACTIVITIES
NURSING ASSESSMENT
Chapter 5, pp. 81-90
A Critical Thinking Approach to Assessment
Collection and verification of data regarding client in
order to develop a database for developing a plan of care based on the derived
nursing diagnosis. Gordon's (1994) functional health patterns list eleven
areas as one guideline (See Box 5-1, p. 82, Typology of 11 Functional Health
Patterns).
Organization of Data Collection
Data Collection
Subjective data - client's perception of
problem. Obtained through interview and health history. Interview
includes orientation, working, and termination phases. (See Box 5-3, p.
86, Strategies for Effective Communication). Communication techniques covered
in lecture. There is logical progression to gathering a complete health
history. (See Box 5-2, p. 85, Gasic Components for a Nursing Health
History)
Objective data - information obtained through
observation or measurement (physical examination, Observation of behavior,
Diagnostic and laboratory data (See Box 5-4, p. 87, Common Laboratory and
diagnostic Tests), Medical Record, health care team members, family members,
and significant others)
Critical Thinking Approach to Formulating Nursing Judgments
Data Interpretation and Validation
Validation
Data Clustering - (See Box 5-5, p. 88, Focused Data Clustering)
Data Documentation
CRITICAL THINKING ACTIVITIES
NURSING DIAGNOSIS
Chapter 6, pp. 92-104
Critical Thinking and the Nursing Diagnostic Process
North American Nursing Diagnosis Association (NANDA) - standardized nursing
diagnoses for all categories. (See Box 6-1, pp. 92-93)
Diagnostic Process
Analysis and Interpretation of Data
Data analysis - analysis of validated and clustered data to identify
patterns (See Box 6-2, p.95, Examples of Data Analysis)
Defining characteristics - validated subjective and
objective data that support a nursing diagnosis (See Box 6-3, p. 95,
Characteristics of Accuracy of Nursing Diagnoses).
Identification of Client Needs
Formulation of the Nursing Diagnosis
Actual Nursing Diagnosis - diagnosis supported by
negative data
Risk Nursing Diagnosis - diagnosis indicated by data
listing causative factors
Possible Nursing Diagnosis - diagnosis indicated by
data that requires further validation
Syndrome Diagnosis - a cluster of diagnoses for a
complex situation. (See
Wellness Nursing Diagnosis - diagnoses supported by
positive data
Nursing Diagnosis Format
related factors - states the contributing factors (See Table
6-1, p.96, NANDA Nursing Diagnosis Format and Figure 6-3, p. 97, Relationship
between diagnostic statement and format)
etiology - must be a problem that can be acted upon with
nursing interventions (See Table 6-2, p. 97, Comparison of Interventions for
Nursing Diagnoses With Different Etiologies)
Assessment Data and the Diagnostic Statement
Assessment data must support the nursing diagnosis which is
formulated based on that data. (See Box 6-5, Summary of Mrs. Bryan's
Relevant Assessment Data, Table 6-3 Formulation of Nursing Diagnoses, and Table
6-4, Defining Characteristics and Etiologies to Support Nursing Diagnoses, pp.
98-99) Data is clustered into the functional patterns, then those bits of
data related to a specific diagnosis become part of the supporting data for
that diagnosis. The "related to" etiology
further clarify how these characteristics contribute to the diagnosis.
Sources of Diagnostic Error
Error can occur in collection, interpretation, clustering,
or labeling (See Box 6-6, p. 98, Sources of Diagnostic Error).
Avoiding and Correcting Errors - (See Box 6-7, p. 100, Avoiding
Diagnostic Errors).
Nursing Diagnoses Versus Medical Diagnoses
Nursing and medical diagnoses are supported by the same data
but the data is analyzed differently according to the professional discipline
and the expertise of each. The outcome goals are different and the
planned interventions/treatments reflect the identified problems, goals and the
diagnosis. (See Box 6-8, p. 102, Comparison of Primary Goals: Nursing and
Medicine and Figure 6-4, p. 102.)
Nursing Diagnoses: Application to Care Planning
Advantages - efficiency, personalized care, effective problem resolution
Limitations of Nursing Diagnoses - language may tend to cause confusion
Priority Setting - allows for setting priorities to meet client needs
Documentation - list nursing diagnoses in priority order.
CRITICAL THINKING ACTIVITIES
PLANNING FOR NURSING CARE
Chapter 7, pp. 106-120
Establishing Priorities
Diagnoses ranked on multiple factors. Involvement of
client in ranking of priorities is valuable. This may be contraindicated
if client is in physical or mental jeopardy. Priorities set as high,
intermediate, and low according to needs (See Table 7-1, p. 106, Priority
Setting)
Critical Thinking and Establishing Goals and Expected Outcomes
Goals of Care - developed in collaboration with client
Role of the Client in Goal Setting - client-centered
Short-term goals - can be achieved in a short period of time
(usually < week); immediately
Long-term goals - to be achieved over long period of time
(weeks/months). May involve rehabilitation, health promotion, prevention
activities, etc.(See Table 7-2, p. 108, Examples of Goal Setting With Expected
Outcomes)
Expected Outcomes - must be written in specific, measurable, objective
terms and and define how the client will have met the goal. (See Table 7-2, p.
108)
Guidelines for Writing Goals and Expected Outcomes
Goals and Expected Outcomes must be from the client's
perspective. There can be no more than one behavior for each expected
outcome. Goals/Expected Outcomes must be observable, measurable,
realistic, time-specific and mutually agreed upon by the nurse and client.
Critical Thinking and Designing Nursing Interventions
The nurse must be able to scientifically explain the
rationale for setting goals and selecting interventions, perform the skills and
use the resources available.
Types of Interventions - Nurses initiate interventions do not require a
physician's order and are based on their scope of practice set by the American
Nurses Association (ANA). Physician-initiated interventions are those interventions
that require a written order from the physician. Collaborative
interventions involve other health care professionals. May require a
physician's written order.
The nurse considers six factors when selecting nursing interventions (See Box
7-2, p. 111, Choosing Nursing Interventions)
Nursing Care Plan
The nursing care plan is an organized, individualized plan
written to reflect the needs of the client, the goals and expected outcomes and
the interventions to be implemented. It is the reference for evaluation
and revision. Various settings structure care plans according to usage
and client needs.
Many institutions use computerized/standardized care plans that address all
probable needs related to the medical diagnosis and the nurse individualizes
the care plan for the client. Critical pathways contain the plan of care
for all disciplines who provide care for the client.
Writing the Nursing Care Plan (See Table 7-4, p.117, Frequent Errors
in Writing Nursing Interventions)
Writing Critical Pathways
Consulting Other Health Care Professionals
IMPLEMENTING NURSING CARE
Chapter 8, pp. 122-132
The nurse implements the nursing interventions and then
continues interventions according to prioritized client needs.
Types of Nursing Interventions
Protocol - a written, recommended treatment plan for
a specific condition or nursing care problem
Standing Order - written orders for specific
treatments, procedures for specific clients.
Critical Thinking in Implementing Nursing Interventions
Implementation Process
Reassessing the Client - is the nursing action appropriate for the
client at this time?
Reviewing and Revising the Care Plan - Do I need to revise my plan of
care based on my new assessment data? If so, I need to add the new data,
revise the nursing diagnosis and interventions and evaluate based on the new
expected outcomes. (See Table 8-2, p. 124, Modified Nursing Care Plan for
Mr. Brown)
Organizing Resources and Care Delivery - for efficiency of care.
Equipment - Are equipment and supplies available and
organized?
Personnel - How can I best provide continuity of care
to each client, given the nursing care delivery system in place?
Environment - Are the surroundings safe, warm,
comfortable, private, and protective for delivery and reception of care?
Client - Physical comfort, level of endurance,
presence of others, time frame, and adequate preparation are important factors
for interventions to be effective.
Anticipating and Preventing Complications - What
physiological/psychological responses are possible as a result of the
intervention for this client's condition.
Identifying Areas of assistance - Do I need someone
to help me? Do I know all I need to know before implementing this intervention?
Implementing Nursing Interventions
Cognitive skills - involves nursing knowledge
Interpersonal Skills - being able to respond
therapeutically to client's verbal and nonverbal communication.
Psychomotor Skills - Integrated cognitive and motor skills
to provide intervention.
Communicating Nursing Interventions - care plan, documentation,
reporting.
Implementation Methods
Assisting With Activities of Daily Living (ADLs) - ambulating, eating,
dressing, bathing, oral hygiene, grooming, and toileting. Can be acute,
chronic, temporary, permanent, or rehabilitative.
Counseling - Using learned techniques to provide emotional,
intellectual, spiritual, and psychological support (See Box 8-1, p. 128,
Examples of Counseling Strategies Used by Nurses).
Teaching - Use assessment, diagnosis, and planning to develop
individualized teaching plan. Present correct skills and/or information
and then evaluate client learning.
Providing Direct Care - To achieve therapeutic goals.
Compensation for adverse reactions - The nurse knows
the potential side effects of the medication, diagnostic test, or intervention
and is prepared to intervene appropriately.
Preventive measures - The nurse acts to prevent
problems through health teaching, counseling, planning, assessment,
documentation, etc.
Correct techniques in administering care and preparing a
client for procedures - know the steps of the procedures and the effects of
the intervention.
Lifesaving measures - Know when and how to use
emergency measures and the expected outcomes.
Achieving the Goals of Care - active or passive client centered, goal
oriented interventions in a protective, supportive environment striving for
client adherence to treatment plan.
Delegating, Supervising, and Evaluating the Work of Other Staff Members
- appropriately assigning personal care aand repetitive tasks to competent
personnel.
CRITICAL THINKING ACTIVITIES
EVALUATION
Chapter 9, pp. 134-145
CRITICAL THINKING SKILLS AND THE DYNAMICS OF EVALUATING NURSING CARE
Evaluation measures the client's response to nursing actions
and the client's progress toward achieving goals with continual redirection of
nursing care based on assessed client needs.
Goals - time specific statement describing what is to be accomplished in
order to resolve a nursing diagnosis.
Expected Outcomes - step-by-step behaviors or responses that demonstrate
achievement the goal(s) of each nursing diagnosis. Must be measurable,
stated in behavioral terms, and time specific.
EVALUATION OF GOAL ACHIEVEMENT
The data is compared with outcome criteria to determine
whether predicted changes have occurred (See Table 9-1, p. 136, Evaluation
Measures to determine the Success of Goals and Expected Outcomes). If
there is no progress, the goal is not met (See Table 9-2, p. 136, Examples of
Objective Evaluation of Goal Achievement).
Evaluative Measures and Sources - use of assessment measures to evaluate
client's status and progress. Sources of data: primarily client:
family, other care givers, written documentation, and oral information.
CARE PLAN REVISION AND CRITICAL THINKING
Discontinuing a Care Plan - If the goals/outcomes are met, the care plan
is discontinued.
Modifying a Care Plan - As a result of evaluation data, if goal is not
met, the care plan is modified to more accurately address needs identified by
reassessment.
Reassessment - compare data collected during
evaluation with previously obtained information.
Nursing diagnoses - reevaluate nursing diagnosis and
etiological factors and develop new diagnosis reflecting changes noted.
Goals and expected outcomes - goals and outcomes are
reviewed and revised if needed.
Interventions - must be based on the standard of care
for the client's health problem. must address solutions to the problems
identified with reassessment.
QUALITY IMPROVEMENT (See Box 9-1, p. 141, Dimensions of Performance)
Multidisciplinary Approach - Team approach involving varied disciplines
to more effectively improve quality initiatives.
Quality Improvement Teams - may be unit based or organization wide,
focus is different.
Components of a QI Program - For health care agencies, the 10 steps for
QI from JCAHO are used (See Box 9-2, p. 142, JCAHO's 10 Steps for Quality
Improvement).
Responsibility for program - the director is
responsible for bringing together the members of the team who then assumes
responsibility for the projects.
Scope of service - team must have an understanding of
who they serve
Key aspects of service - identify key aspects of
service by high volume, high risk, and problem areas.
Developing quality indicators - tools measuring
quality of service according to requirements.
structure indicators -
measure systems for delivering care;
process indicators - evaluate
how care is given;
outcome indicators - evaluate
end result of care delivered.
Establishing thresholds for evaluation - A threshold
is a standard for determining whether a problem exists.
Data collection and analysis - monitoring specific
criteria and collection of information on a sufficient number of clients then
analyzing the data to identify potential problems.
Evaluation of care - monitoring indicators to
determine if quality of care meets criteria.
Resolution of problems - develop a plan of action
designed to improve the process and expected outcomes.
Evaluation of improvement - reevaluate the success of
the plan.
Communication of results - results of findings must
be communicated to staff effectively in order for improvements to take place.
CRITICAL THINKING ACTIVITIES
DOCUMENTATION AND REPORTING
Chapter 14, pp. 224-243
Health care reimbursement may depend on the completeness of the documentation of interventions by all disciplines. Accurate information insures continuity of care for clients.
MULTIDISCIPLINARY COMMUNICATION WITHIN THE HEALTH CARE TEAM
Nurses, pharmacists, laboratory technicians and other disciplines report oral, written, and audio taped information regarding clients. Documenting in the client record provides a permanent, legal, written communication of the interventions, status, referrals, etc. Consultation is a formal discussion between professional care givers for formal advice in client care.
DOCUMENTATION
Contents (See Box 14-4, p. 225, General Information Contained in a Medical
Record)
Purpose of Records
Communication - way for health care givers to
communicate information regarding client for continuity of care.
Legal documentation - record can be used in
court. inadequate documentation include: (1) not charting correct time,
(2) failing to verbal orders or have them signed by ordering attending, (3)
charting actions in advance, and (4) documenting incorrect data. (See Table
14-1, p. 226, Legal Guidelines for Recording)
Financial billing - verifies care provided to justify
reimbursement.
Education - provides patterns of information for
clients with similar conditions.
Assessment - provides new and updated data for nurse's
ongoing assessment of client.
Research - statistical data can be gathered when
research is done .
Auditing and monitoring - quality improvement
programs routinely review client records for quality and appropriateness of
care. Deficiencies identified are basis for quality improvement
initiatives.
GUIDELINES FOR QUALITY DOCUMENTATION AND REPORTING
Factual Basis - must be descriptive, objective information the nurse
sees, hears, feels, or smells. Subjective data only when verbalized by client.
Accuracy - Use precise measurements; correct spelling; and accurate
date, time, description and signature.
Completeness - should be complete, concise, and thorough.
Currentness - vital signs, medication administration, special client
preparation, status changes, treatment for changes, and subsequent client
response, and disposition of client are entries that need to be charted without
delay. (See Table 14-2, p. 227, Comparison of Military/Civilian Times)
Organization - Chart in the order of occurrences.
Confidentiality - all information is confidential and to be accessed
only by authorized persons.
METHODS OF RECORDING
Narrative Documentation - traditional method. no single correct
order. easy to use in emergency.
Problem Oriented Medical Records (POMR) - organized by problem or
diagnosis.
Database - contains assessment data as foundation for
diagnosis and planning.
Problem list - chronological list of problems/nursing
diagnoses and updated with each assessment
Care plan - developed for each problem/nursing
diagnosis
Progress notes - entries made by each health care
team member
SOAP documentation - subjective and objective data,
assessment, and plan. If SOAPIE the interventions and evaluation
added. Medical model.
PIE documentation - Nursing model. address
problem, interventions, and evaluation.
Source Records - each discipline has separate form for data entry.
fragmentation of data, difficult to locate. (See Table 14-3, p. 229,
Organization of Traditional Source Record)
Charting by Exception - nurse writes longhand notes only when the
standardized norms are not met
Focus Charting - charting focused on data, actions, and client response
(DAR). does not require formal nursing diagnoses. (See Table 14-4,
p. 230, Examples of Focus Charting).
Case Management Plans and Critical Pathways - Case management plans are
multidisciplinary integrated care plans for the problems, key interventions,
and expected outcomes of the client with a specific disease or condition.
These plans are organized into a printed, multidisciplinary, daily plan of care
listing outcomes and interventions for each day (See Table 14-1, p. 232-233,
Critical path for MS). Positive variances occur when client achieves
outcome before projected time. Negative variances occur when client does
not achieve outcome at predicted time or complications occur (See Table 14-5,
p. 231, Example of Variance Documentation). Benefits of Case Management
and Critical Pathways are listed in
Common Record Keeping Forms
Admission nursing history forms - Contains
biographical data, holistic assessment, review of health risk factors, and
identification of current problems (See Figure 14-2, p. 234).
Graphic sheets and flow sheets - quick, efficient
method for recording routine measurements/observations (See Figure 14-3, p.
235, Nursing Assessment Flow Sheet).
Kardex and client care summary - flip over card
updated manually or by computer giving plan of care, activities and treatments.
Twenty-four-hour client care records and acuity charting
forms - necessary to determine client acuity for assignment and staffing
levels. utilizes flow sheets and checklists for efficiency.
Standardized care plans - preprinted. based on
practice standards of institution. nurse responsible to judge appropriateness
of care plan and to individualize plan to client needs.
Discharge summary forms - provided to client on
discharge with reason for hospitalization, significant findings, client's status
and specific teaching plans to ensure better continuity of care (See
Home Health Care Documentation - Must be accurate and complete for
reimbursement (See Box 14-4, p. 237, Multidisciplinary Example of Health Care
Team Working Together).
Long-Term Care Documentation - multidisciplinary approach in assessment
and planning support sound documentation to justify need for nursing care.
Computerized Documentation - At present, used mostly for ordering
supplies, diagnostic tests, equipment, and medications. In the future,
nurses can expect to utilize for charting. Great need for measures to
assure confidentiality of information. Virtual reality in the future may
influence computerized documentation.
REPORTING
Change-of-Shift Report - given orally, audio taped, or on
rounds. should be organized, concise, professional, and given quickly and
efficiently. (See Box 14-5, p. 239, Sample Taped Change-of-Shift
Report)
Telephone Reports and Orders
Telephone reports - should be clear, accurate, and
concise and documented.
Telephone orders - clarify and verify by repeating to
physician then write order on order sheet and sign. Have physician sign
within set time. See
Transfer Reports - information transferred from nurse transferring
client to nurse receiving client. Answer any questions to clarify
client's status.
Incident Reports - a written report of any event not consistent with
routine care or operation of a unit. Should be concise and accurate. Is
not a part of the legal chart. Do not chart generation of incident
report. (See Box 14-7, p. 242, Guidelines for Completing an Incident Report)
Nursing Process: Definition | Critical Thinking | Guidelines
Critical Thinking:
Characteristics | Skills, Elements,
Standards
Nursing Process: Assessment | Nursing Diagnosis | Planning | Implementation | Evaluation
John
Philip Tiongco, MD