PNUR 124 WEEK 1 THE NURSING PROCESS, CRITICAL THINKING, & DOCUMENTATION11 (20).pptx

The Nursing Process By: Joan Taylor-Willis Revised by: Dennise Morgan  What is the Nursing Process It is systematic with use of critical thinking An assertive, problem-solving approach to the identification and treatment of patient health issues. Provide NURS...

The Nursing Process By: Joan Taylor-Willis Revised by: Dennise Morgan  What is the Nursing Process It is systematic with use of critical thinking An assertive, problem-solving approach to the identification and treatment of patient health issues. Provide NURSING PROCESS Framework to organize the knowledge, judgements, and actions that nurses supply during patient care. Identifies client strengths, their needs and develop specific nursing interventions in collaboration with the client to meet common outcomes. Client-centered; Individualized care Collaboration and trust (Tyerman & Cobbet, 2023. p. 12)  The Nursing Process Assessment Diagnosis Planning Implementation Evaluation https://www.pinterest.ca/pin/365143482261172277/  The Nursing Process Assessment: collection of data to establish client’s baseline/response to health concerns. E.g physical assessment Diagnosis: involves analysis of the data collected. Identify client’s strengths, problems and any gaps. Develop nursing dx. Planning: develop individualized care plan on how to address identified problems. Construct desired outcomes/goals using the SMART format.  The Nursing Process Implementation: carry out the plan of care, performing nursing interventions. Document results. Evaluation: measuring the degree to which outcomes/goals were met. Look at barriers to goal achievement. Review and modify care plan as needed. https://onlinenursing.cn.edu/news/importance-holistic-nursing-care  Types of Data Objective data: BP 120/75,HR 92, skin pale and diaphoretic Subjective data: “My pain is 10/10” “I am having difficulty breathing when I lie down” Primary source of data: directly from the client Secondary source of data: from all other sources (client, chart, reports, labs, family)  Data Collection Why should the nurse validate the data collected? (for analysis and interpretation of data) Cues: can be subjective/objective (information obtained through use of the senses) Inferences: the nurses’ judgement or interpretation of the cues (the client is diaphoretic, and grimacing while guarding the abdomen. The client has abdominal pain). Potter et al., 2019, p.191 Concept Map What is a concept map, and how can it be used in the nursing assessment process? A visual representation that shows the connection between the client’s issues/problems (Potter et al., 2019) Promotes critical thinking. How ? https://journals.rcni.com/nursing-standard/concept-mapping-a-tool-for-improving- patient-care-ns.29.48.49.e9903 Nursing Diagnosis/Problem Statements Judgement made after collecting and analyzing data. Involves clinical reasoning. Priority is established based on the urgency of the issue and impact on patient safety. ( client with CHF and congested non-productive cough, priority would be airway clearance) Nursing dx can be actual or risk for. Can you differentiate? Nursing Diagnosis/Medical Diagnosis Nursing Dx Medical Dx. Based on nursing judgment Made by physician or NP Nurses can treat client presenting Can only be treated by NP/MD condition Focuses on the disease process Is multifaceted (holistic response to illness or health issue) Presentation is similar among Varies among individuals individuals This diagnose remains the same Can change as client response changes as long as disease is present. (Kozier et al., 2018, p.430)  How to Write a Nursing Diagnosis (NANDA) P: stands for the problem E: stands for the etiology (factors contributing to or probable cause of the problem S: signs and symptoms of the problem Examples: 1) Impaired skin integrity related to immobility as evidenced by stage 2 pressure ulcer on sacrum 2) Ineffective airway clearance related to thick mucoid secretions secondary to COPD exacerbation as evidenced by: hypoxia, SPO2 of 86%, dyspnea, weak cough etc.  Critical Thinking What is critical thinking? Critical thinking is the ability to make judgements and solve problems by making sense of information Critical thinking is knowing how to learn, be creative, generate ideas, make decisions, and solve problems Learning and using critical thinking is an ongoing process that happens in and outside of the clinical setting. Tyerman & Cobbett, 2023. p.10  Critical Thinking Critical Thinking is a systematic process that facilitates the nurse and client in making informed decisions. It is reflective and reasonable thinking. It is guided by standards policies and ethical consideration Is Based on the principles of the nursing process, problem solving and the scientific methods Applies logic intuition and creativity Focus on patient safety Driven by patient family and community needs Potter et al., 2019  Characteristics of the Critical Thinker Curiosity: Have desire, not just to know, but to understand how and why, to apply knowledge Systematic thinking: Organized approach to problem solving Analytical: Applies knowledge from different discipline; looks at parts of an issue to see how they connect Open-minded: Consider other alternatives Self-confident: assurance that plan is viable Truth-seeking: Apt to learn/know, ask questions and reevaluates own “common knowledge” Critical Thinking and Clinical Reasoning https://www.slideshare.net/jamesaloslideshare/critical-thinking-nursing-process-drjma Critical Thinking Clinical Judgment “The ability of a nurse to apply their knowledge, experience, and critical thinking abilities to make well-informed decisions concerning a patient's care is referred to as clinical judgment. It entails compiling data from numerous sources, including patient histories, assessments, medical records, and lab results, then applying that knowledge to create treatment plans and analyze their effectiveness.” https://nursing.uworld.com/nclex-pn/test- plan/  Ways of Knowing Who you are, and your values will influence your future nursing practice. Professional Ways of Knowing: Empirical “science of nursing” –is concerned with the objective, abstract, and general knowledge that is quantifiable and verified through repeated testing over time (Carper, 1978, 1992) ---comes from theoretical knowledge and research-based evidence. (we treat an infection with abx) Aesthetic Knowing “art of nursing” – The nurse uses different approaches based on client context and the nurse's personality and creativity. Esthetic knowing assists the nurse in seeing the whole picture from an evaluative standpoint and envisioning the outcome of the creative actions chosen for a specific situation (Carper, 1978, 1992).  Ways of Knowing Ethical Knowing: Shaped by our personal values. In nursing, this patter of knowing is shaped by professional values and standards (CNA and CNO Code of Ethics)….maintain privacy, client dignity, compassionate care etc. Personal Knowing: The knowledge that the nurse brings to the profession. “Involves the interactions, relationships and transactions between the nurse and the client (Carper 1978, as cited in Potter et al., 2019)  Application Example A 48 years old Aboriginal male reports having severe headache. He has a BMI of 30. Vital signs: BP 180/95, P 97, Temp 37.2, SPO2 93% on R/A. He takes his antihypertensive medications occasionally and has not seen his health care provider in the past 2 years. He is self employed as a gardener. Lives with wife mother-in-law and four children. He did not complete high school.  The Critical Thinker Approach… Will defer diagnosis until more data is obtained The critical thinker will understand that the client’s point of view might be different from his Will recognize the patient erratic use of medication may have multiple causes and will not infer a diagnosis until more information is obtained Will examine assumptions, for example an increased in knowledge will increase compliance https://today.mims.com/nurses--ways-you-can-develop-critical-thinking-skills http://news.sunybroome.edu/focus/critical-thinking-critical-care-nick-starts-his-nursing-career-in-the-icu/  Planning  After the nursing diagnosis/collaborative problem is identified, the nurse must identify the urgency of the identified problem  Priority setting the nurse must prioritize actual problems over potential problems  Diagnosis of highest priority needs immediate intervention, those of lowest priority can be addressed later.  First intervene for life threatening problems AIRWAY, BREATHING, CIRCULATION  Use Maslow’s hierarchy of needs to determine priority  Determine the patient’s perception of what is important The nurse must also consider: Concepts of motivation Change theory/Behaviorism/Humanism Cultural competence in nursing  Appropriate Care Plan… What would be your priority nursing dx? Provide two patient outcomes/goals based on the Nursing dx chosen: List two nursing intervention:  Implementation  Carrying out the specific, individualized plan for the patient  The nurse needs sound knowledge, good judgement, and decision-making ability to chose the appropriate nursing intervention  Nursing intervention can be independent or dependent. Can you identify the difference?  The Critical thinker considers the implications and consequences of selected nursing strategies before implementing plan of care  Questions to Consider? What are patients goals and outcomes?  Cultural values, beliefs and needs  Evaluation All phases of nursing process must be evaluated Evaluation occurs after implementation of the plan but also continuously throughout the process The nurse evaluates if sufficient data is obtained to make the nursing diagnosis, then the diagnosis is evaluated for accuracy The nurse collaborates with the patient to determine if interventions are: met, partially met, or unmet  Documentation DOCUMENTATION The nursing action defined as “the process of documenting nursing information about nursing care in health records” Vital aspect of nursing practice Critical for patient’s progress to be documented in a systematic way Information in a patient record provides detailed account of level and quality of care provided Provide evidence of a clients care Documenting and reporting practices differ among institutions, and jurisdictions and are influenced by ethical, legal, medical and agency guidelines Reporting Oral written or computer based communication i.e. progress report at the end of a shift  Documentation Many documentation methods and formats are used depending on personal preferences, hospital policy, and regulatory standards Ethical and Legal Implications The College of Nurses of Ontario (CNO) outlines values for practice Documentation and reporting are guided by the code of ethics Responsible and accountability Clients record is a legal document Ethical and Legal Implications Your documentation is kept for 10 years therefore you could be summoned to court to testify several years after your interaction with a client. The memory may fade but accurate timely and objective documentation will allow recollection and add credibility to your testimony Poor grammar and careless entry can compromise the entire client record Flowsheets, graphics, progress notes, late entries and intervention records are all a part of the client’s chart Documentation Should be…. Clear and concise Accurate and relevant Completed in a timely manner Avoid subjective opinion Use objective language Respect for diversity Do not erase, apply correction fluid or scratch out errors (written) Do not leave blank spaces https://ehrintelligence.com/features/what-are-the-benefits-of-clinical-documentation-improvement-cdi  Confidentiality and Privacy The Canadian Health Infoway is responsible for digital health information and the overall security of patient information The mandate is to improve the health of Canadians and collaborate with partners to develop and adopt the effective use of digital health across Canada Nursing Roles and responsibility: Do not share your personal password with anyone Never leave your computer terminal unattended See CNO Practice Standards: Documentation https://www.wrh.on.ca/uploads/Common/Intranet/Safe%20Medication%20Bundl es/CNO%20practice%20standard%20documentation%202008.pdf  Nursing Responsibility Do not leave patient information display for others to read Follow agency policy and for documenting sensitive information Log off when work is completed Inform you manager of a security breach Avoid discussing client’s personal health information in the lunch room, elevators or on social media!! Potter & Perry, p. 235  Methods of Documentation Narrative Documentation Method traditionally used to record patient assessment and nursing care provide Story-like format to document information Can be done in the free text section when electronic documentation is used Time consuming and repetitious  Problem-Oriented Medical Record (POMR) Also called problem oriented record Data arranged according to the patient’s individual problem/diagnosis rather than the source of information. Extensive documentation on admission Other Types of POMR Data base (has all client available assessments by different disciplines) Problem list – generated from analysis of patient data/problem Care Plan – includes nursing diagnosis, expected outcomes & interventions Progress notes – the health care team monitors and record the progress made toward resolving a patient’s problem in the progress notes  Problem-Oriented Medical Records SOAP S: Subjective data (verbalization of the patient) O: Objective data (that which is measured & observed) A: Assessment (diagnosis based on data) P: Plan (what the caregiver plans to do) Similar to the NP. Each SOAP note is numbered and titled according to the problem on the list.  Problem-Oriented Medical Records SOAPIER S: Subjective data O: Objective data A: Assessment P: Plan I: Interventions E: Evaluation R: Revision  Problem-Oriented Medical Records Focus Charting Involves the use of data-action response DAR notes: The clients concerns are the focus of care The focus could be a condition, a nursing diagnosis, a behavior, a sign or symptom or a change in clients condition  Focus Charting Three columns used for documenting (Date and Time, Focus (system), and Progress note) D: Data (both subjective and objective) A: Action (nursing intervention) R: Response of the patient (evaluation of effectiveness)  Source-Oriented Documentation In a source record, the patients chart is organized so each discipline (e.g. nursing, medicine, social work) make notation on a separate section One advantage is that caregivers can easily find the correct section to document One disadvantage is that details about a specific problem may be spread across the record Nurses may enter narrative description of patient care/response Time consuming and repetitious (have to search for specific data)  Charting by Exception (CBE) The philosophy behind CBE is that the patient meets all standards unless otherwise documented Many computerized documentation systems use CBE design Involves standards of care, evidence-informed interventions, and clearly defined criteria of nursing assessment and documentation (normal findings) The pre-defined statement used to document NORMAL nursing assessment of body systems are called “within defined limits, WDL or within normal limits (Potter & Perry, 2024, p.242)  Charting by Exception (CBE) WDL or other statement chosen from a pre-defined drop down menu Nurse writes a progress note only when a patient’s does not meet the standard normal criteria, “not within defined limits, NWDL” When changes in a patient’s condition occurs, the nurse needs to document thorough and precise description in the progress notes Common Record Keeping Forms Admission Nursing History Forms Flow sheets and graphic records Patient Care Summary or Kardex Standardized Care Plan Discharge Summary Forms Documenting Communication with Providers Telephone order (TO) and Verbal orders (VO) TO occur when a HCP gives therapeutic orders over the phone to a RN or HCP VO occur when a HCP gives therapeutic orders to another HCP while they are standing close to each other TOs & Vos often occur at nights and during emergency Check institution policy regarding receiving TOs & Vos The HCP receiving the TO or VO should document it clearly in the patients chart or for pharmacy Verify order by “read-back” and then document Documenting Communication with Providers Change of Shift Report, patient handover, transfer of accountability (TOA), bedside reporting, shift handover At the end of each shift, the nurse reports pertinent information about the client to the oncoming nurse Crucial for patient safety Describes patient’s status and says what kind of care patient requires Transfer Reports – given when patient is transferred from unit to another (provide Pt’s name, demographics, code status, allergies, etc.) Documenting Communication with Providers Nurses communicate information about patients so all members of the team can make appropriate decisions Any verbal report must be timely, accurate, and relevant Situation-background-assessment-recommendation (SBAR) or Identification-situation-background-assessment- recommendation-repeat back (I-SBAR-R) used to share important patient information Situational briefing system that fosters a culture of patient safety E.g., nurse reports to MD about a critically ill patient, change of shift reports Incidence or Occurrence Report Any event that is not considered a part of the routine or expected care of the patient or standard of the unit For example, a patient or family member falling, needle stick injuries, medication errors, a visitor with symptoms of an illness. Completed whenever an incident (or near miss) occurs Part of the quality improvement program Nurse gives objective description of what was observed, follow-up actions, including notification of HCP, patient’s response Reports confidential and limited to those responsible for reviewing them Helps to change policies and procedures DO NOT include any reference about an incident report in the patient’s medical record  References Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M., Barry, M., Lok, J., Tyerman, J., & Goldsworthy, S. (2019). Medical-Surgical Nursing in Canada: assessment and management of clinical problems (4th ed). Milton, ON: Elsevier Health Sciences. Potter, P.A., Perry, A.G., Stockert, P.A., Hall, A., Astle., B., & Duggleby, W. (2019). Canadian fundamentals of nursing (6th ed.) Toronto, ON: Elsevier. Tyerman, J., Cobbett, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., Reinisch, C. (2023). Lewis's Medical-Surigical Nursing in Canada: Assessment and management of clinical problems (5th ed). Toronto, ON: Elsevier Canada. https://nursing.uworld.com/nclex-pn/test-plan/