Nursing Process & Critical Thinking

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Who is considered the major proponent of Nursing Process?

Ida Jean Orlando

What is the nursing process?

A 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.

Conflicting data or information in the nursing process is known as Inconsistency. (True/False)

True

Objectives of nursing diagnoses include identifying clients' health status, actual or potential health needs, and establishing plans to meet those needs by delivering specific nursing _____.

interventions

Match the following types of nursing diagnosis with their descriptions:

Actual diagnosis = Client problem present at the time of assessment Risk nursing diagnosis = Clinical judgment that a problem does not exist, but there are risk factors

What is the purpose of standard precautions in healthcare?

To prevent the transmission of infectious agents and break the chain of infection.

Study Notes

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.

Learn about the five-step process of critical thinking used by professional nurses to apply evidence-based caregiving. Explore the contributions of notable nursing theorists like Abraham Maslow and Ida Jean Orlando.

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