Nursing Process & Critical Thinking

Nursing Process and Critical Thinking

• Nursing process is a critical thinking five-step process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness.
• It develops analysis and decision-making skills.

Nursing Theorists

• Abraham Maslow developed the Hierarchy of Needs.
• Ida Jean Orlando is considered a major proponent of the Nursing Process.

Nursing Process Importance

• There should be no missing data or gaps in the nursing process.
• Conflicting data or information is known as inconsistency.

Nursing Process Definition

• It is a systematic, rational method of planning and providing individualized nursing care.
• Its purpose is to identify clients' health status, actual or potential health needs, and establish plans to meet those needs.

Types of Data

• Subjective data (also referred to as symptoms or covert data) are provided by the client.
• Objective data (also referred to as signs or overt data) are detectable by an observer.

Sources of Data

• Primary source is the client.
• Secondary sources include family, significant others, healthcare team, medical records, and scientific literature.

Methods of Data Collection

• Observing: gathering data using the senses.
• Interviewing: a planned communication or conversation with a purpose.
• Examining: a systematic data-collection method that uses observation to detect health problems.

Purposes of Nursing Diagnosis

• Helps identify nursing priorities and directs nursing interventions.
• Helps formulate expected outcomes for quality assurance and third-party payers.
• Provides a common language and forms a basis for communication and understanding between nursing professionals and the healthcare team.
• Provides a basis of evaluation to determine if nursing care was beneficial to the client and cost-effective.

Types of Nursing Diagnoses

• Actual diagnosis: a client problem that is present at the time of nursing assessment.
• Risk diagnosis: a clinical judgment that a problem does not exist, but the presence of risk factors.
• Wellness diagnosis: a clinical judgment about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness.
• Syndrome diagnosis: a cluster of problems.

Examples of Nursing Diagnoses

• Actual: Ineffective Breathing Pattern, Altered Thermoregulation, Disturbed Body Image, Fatigue, Activity Intolerance.
• Risk: Risk for Infection, Risk for Impaired Liver Function, Risk for Impaired Skin Integrity.
• Wellness: Effective Therapeutic Regimen, Readiness for Enhanced Spiritual Well-being.
• Syndrome: Rape-Trauma Syndrome, Disuse Syndrome, Post-Trauma Syndrome, Impaired Environmental Interpretation Syndrome.

Goal Setting

• Patient-centered goals: "Patient will ambulate independently in 3 days", "Patient will report sleep improvement", "Demonstrate progressive weight gain towards goal".
• SMART goals: Specific, Measurable, Achievable, Relevant, and Time-bound.

Planning and Discharge Planning

• Initial planning: admission assessment.
• Ongoing planning: continuous assessment and evaluation.
• Discharge planning: MEDICATIONS, EXERCISE, TREATMENT/THERAPY, HYGIENE, OUT-PATIENT FOLLOW-UP, DIET/NUTRITION, SEXUAL ACTIVITY/ SPIRITUALITY.

Medical and Surgical Asepsis

• Medical asepsis: reduces microorganisms.
• Surgical asepsis: destroys all microorganisms.
• Aseptic technique: used to prevent or minimize contamination of wounds and other susceptible sites during procedures.

Principles of Asepsis

• All items in a sterile field must be sterile.
• Sterile persons touch only sterile articles.
• If in doubt about the sterility of anything, consider it unsterile.
• Unsterile persons avoid reaching over sterile fields while sterile persons avoid leaning over unsterile areas.
• Tables are sterile only at table level.
• Gowns are considered sterile only from the waist-shoulder level and the sleeves.
• The edge of anything that encloses sterile contents is considered unsterile.
• Sterile persons keep within the sterile area.
• Non-sterile persons keep away from sterile areas.
• Moisture may cause contamination.
• When bacteria cannot be eliminated from a field, they must be kept to an irreducible minimum.
• Destruction of integrity of microbial barriers results in contamination.

Standard Precautions

• Used with any patient, regardless of their known or suspected infection status.
• Assume any patient's blood or body fluid may be infectious.
• Consider what type of infections control practices should be used based on the level of anticipated contact with the patient.
• Key points about personal protective equipment (PPE) use:
  • Selection of PPE is based on the nature of the patient interaction and potential for exposure to infectious material.
  • Put on (don) PPE prior to coming into contact with the patient.
  • Be aware of self-contamination when PPE is used.
  • Perform hand hygiene after PPE removal.
• Preventing transmission of infectious agents: one of the most important strategies to prevent transmission of infectious agents.