Nursing Process Overview PDF

The Nursing Process Overview COURSE OUTCOME  Describe principles of safe, patient-centered, evidence-based nursing care to adults at the basic level, guided by the Caritas philosophy. COMPETENCY Describe the elements of the nursing process.  CONCEPT  Clinical Decision Making:...

The Nursing Process Overview COURSE OUTCOME  Describe principles of safe, patient-centered, evidence-based nursing care to adults at the basic level, guided by the Caritas philosophy. COMPETENCY Describe the elements of the nursing process.  CONCEPT  Clinical Decision Making: A process used to examine and determine the best actions to meet desired goals; requires anticipating, recognizing and organizing patient problems to respond with urgency and/or importance in a preferential order to avoid or minimize adverse changes in a patient’s condition. UNIT OUTCOMES  Nursing Process: Overview  Discuss the relationship between the nursing process and critical thinking.  Describe the steps of the nursing process.  Role Of the Caring Nurse  Advocate  Protect, promote, and optimize health and prevent illness and injury  Requires critical thinking  Critical Thinking  Think through each situation  (question, analyze, interpret, reason)  Use information/data to reason and make inferences  (synthesize, create, intuition, application)  Try to picture what the client is experiencing  (inference)  Learning and thinking never ends End product of critical thinking is clinical judgment  Knowledge Base  Experience  Competence  Attitudes  Standards Nursing Process: ADPIE  Organized  Dynamic  Patient Centered  Problem solving process  Decision making at each phase Five-Step Nursing Process Assessment/Recognizing Cues  Systematic collection of data  Continuous  All phases of nursing process  Used to predict health risks  Primary and secondary  Cultural considerations and assessment Analyzing Information/Prioritize Hypotheses  Cluster assessment data to identify problems  What is the patient’s NURSING problem?  Clinical judgment of the human response to illness/injury  Basis for nursing actions  Medical diagnosis vs nursing diagnosis  Examples of Nursing Diagnoses: Mobility - Impaired Physical Mobility Nutrition - Altered Nutrition NANDA Planning/Generate Solutions  Planning goal and outcome  What do you want to happen?  Timeframe  When do you want it to happen? Implementation/Take Action  Actions directed to meet the patient goals  Performing the nursing interventions Evaluating Outcomes  Did the interventions work?  Collect data to determine if the nurses action has facilitated goal achievement Brief Overview: Nursing Process  Assessment – Patient Data Collected  Analyzing information – Patient Problem  Planning- Patient goals and outcomes created the patient will ____ by set time Brief Overview: Nursing Process  Take Actions- Nurse Actions  The nurse will do ____ to resolve the patient’s problem Ex. The nurse will provide pain medication to the patient 30 minutes prior to physical therapy.  Evaluating outcomes of the patient status occurs after Implementation (taking actions) by the nurse  the patient (past tense verb) walked Clinical Judgment Model  Developed to augment the standard nursing process to help sound decision making  Recognize Cues  Analyze Cues  Generate Solutions  Take Actions  Evaluate Outcomes Clinical Judgment Model Clinical Judgment Model pg. 2505 Questions