Nursing Process And Clinical Judgment Model PDF

The Nursing Process and Clinical Judgement Model Nursing Process, Critical Thinking, and Clinical Judgment 1) Explain the use of the nursing process. 2) Identify the components of the nursing process. 3) State what “critical thinking” means. 4) Identify the steps used in making decisions. 5) Di...

The Nursing Process and Clinical Judgement Model Nursing Process, Critical Thinking, and Clinical Judgment 1) Explain the use of the nursing process. 2) Identify the components of the nursing process. 3) State what “critical thinking” means. 4) Identify the steps used in making decisions. 5) Discuss critical thinking in nursing. 6) Identify ways to improve critical thinking. 7) Explain priority setting for nursing care. 8) Apply critical thinking to a real-life problem.  A way of thinking and acting based on the scientific method.  Used as a tool identify patients’ problems and an organized method to meet patients’ needs.  Components of the nursing process  Assessment (Recognize Cues)  Data Analysis/Problem Identification (Analyze Cues/Prioritize Hypotheses)  Planning (Generate Solutions)  Implementation (Take Action)  Evaluation (Evaluate Outcomes)  Collecting, organizing, documenting, and validating a patient’s health data  Data are gathered from patient (physical assessment and interview) and family, as well as from the physician and patient’s medical record  Data from other health professionals and diagnostic tests included in assessment  Sorting and analyzing the assessment data to identify potential health problems  Problems identified during the process are specific nursing diagnoses  Nursing diagnoses prioritized and entered into the nursing plan of care  A series of steps in which the nurse and the patient set priorities and goals to eliminate, diminish, or control identified problems  Goals should be stated with specific outcomes  Nurse and patient collaborate to choose specific interventions to enable the patient to meet the specific outcomes listed in the plan of care  Carrying out nursing interventions prioritized during the planning process  Some interventions may be delegated or carried out by other members of the health care team  Assessing the patient to evaluate his or her response to the nursing interventions  Responses compared with expected outcomes to evaluate whether outcomes have been met  Based on results from the evaluation process, the nursing plan of care may need to be changed  Required to use the nursing process successfully  Means requiring careful judgment  Directed, purposeful mental activity by which ideas are evaluated, plans are constructed, and desired outcomes are decided  Decisions are necessary to solve problems.  Nurses make decisions in each step of the nursing process.  Good decision making is choosing the best actions to meet a desired goal and is part of the critical thinking process.  Define the problem clearly.  Consider all possible alternative solutions to the problem.  Consider the possible outcomes of each alternative.  Predict the likelihood of each outcome occurring.  Choose the alternative with the best chance of success and the fewest undesirable outcomes.  Effective reading  Effective writing  Attentive listening  Effective communicating  Requires skills and experience as well as knowledge  Influenced by professional standards and codes of ethics  Critical thinking and the nursing process  Assessment: organized and systematic; includes gathering and recording data  Nursing diagnosis requires analysis of data gathered, clustering related information, identifying problem areas, and choosing appropriate nursing diagnoses  Planning involves determining specific desired outcomes for each nursing diagnosis  Critical thinking and the nursing process  Implementation involves preparing for and performing the interventions  Evaluation involves gathering data to determine if expected outcomes have been achieved Which of the following is an example of a nurse’s statement that reflects using the scientific method in the nursing process? 1) “I believe that this patient is getting depressed.” 2) “The patient doesn’t look right to me; I think something is wrong.” 3) “The patient’s husband told me that she is feeling very uncomfortable.” 4) “The patient reports more pain than yesterday and her blood pressure is elevated.”  Priority setting (prioritizing): placing nursing diagnoses/interventions in order of importance  High priority: life-threatening problems  Medium priority: problems that threaten health or coping ability  Low priority: problems that do not have a major effect on the person if not attended to that day or week  Priorities change as patient conditions change  To maintain an organized workload you must:  Write out a worksheet; list major tasks to accomplish  Be flexible and frequently reorder your tasks  Evaluate and reprioritize work plan at least every 2 hours  Know when to ask for help and when to delegate a task to others  Goal is to avoid having your decision cause injury to anyone  With critical thinking skills, you can weigh many factors and skillfully solve problems, making good decisions a majority of the time  Operating in critical thinking mode while pursuing nursing studies helps develop clinical judgment needed to practice safe nursing Which of the following nursing actions is the best example of problem solving? 1) Requesting the IV team to start an antibiotic drip on a patient with a history of being a difficult stick 2) Offering to call the kitchen to provide an alternate breakfast for a patient who does not like cooked cereal 3) Trying several difficult wound dressings to determine which one the patient can apply the most effectively 4) Calling for another pain medication order when the current drug results in the patient experiencing nausea Assessment, Data Analysis/Problem Identification, and Planning 9) Identify the purpose of data collection. 10) Discuss methods used to gather data from a patient. 11) Differentiate between subjective and objective data.  To gather information about patients and their needs  During assessment, the nurse collects patient health data  Data are gathered on specific topics, organized into a database, and documented  LPN/LVNs may be asked to collect data as part of the assessment  Approaches to assessment  Functional health patterns assessment as formulated by Mary Gordon, p. 60  Focused assessment (focuses on a specific problem)  Basic needs assessment based on Maslow’s hierarchy of basic needs Subjective Data Objective Data Obtained from the Obtained through the patient verbally senses and hands-on physical exam  “headache”  Vital signs  “nausea”  Lab reports  “sad”  Presence/absence of visitors This is what the patient This is what you observe (with complains of, specifically says your own eyes, ears, etc.) to you  Based on gathering data—is not a social interaction  Good communication essential  Communication may be:  Verbal  Nonverbal, noting body posture, facial expressions, movement, and gestures  Consists of three basic stages  The opening, during which rapport is established with the patient  The body of the interview, during which necessary questions are presented  The closing, during which information is summarized  Data collection tool; helps obtain information to interview patient or prepare for the day’s patient assignment  Medical records (chart) review should include:  Face sheet and physician’s orders  Nurses’ notes (at least the past 24 hours)  Physicians’ progress notes and history and physical examination  Medication administration record  Surgery operative report and pathology report  Diagnostic tests  Nursing admission history and assessment  Fall risk assessment and skin assessment  Nursing care plan or problem list  Use techniques of inspection, auscultation, palpation, and percussion  Carried out in a systematic manner  Head-to-toe examination  Ongoing nursing data collection and examination focuses on the body systems in which there is a problem or potential problem  Initial observation  Breathing  How the patient is feeling  General appearance  Skin color  Affect  Head  Level of consciousness  Awake, alert, and oriented  Ability to communicate  Language spoken, any communication deficits  Mentation status  Able to comprehend, form thoughts  Appearance of the eyes  Pupil size, light reaction  Vital signs  Temperature  Pulse rate  Rhythm, strength, apical, radial  Respirations  Rate, pattern, depth; oxygen saturation  Blood pressure  Within normal limits  Compare with previous readings  Heart and lungs  Heart sounds, normal S1-S2  Lungs  Lung sounds  Rales, wheezes, diminished breath sounds  Abdomen  Shape, hardness, bowel sounds, last bowel movement, voiding, appetite, nausea  Extremities  Ability to move all extremities well  Ability to move within normal range  Skin turgor, color, temperature  Peripheral pulses  Edema  Tubes and equipment  Oxygen cannula, chest tubes  NG tubes, PEG tubes, jejunostomy tube  Urinary catheter  Type and amount of drainage  Dressings and drainage  Pulse oximeter  Traction devices  Pain status  Extensive initial assessment performed when patient enters long-term care facility  Reassessment at fixed intervals and as the patient’s condition changes  Physical assessment, health history, medication history, and a functional assessment performed  Initial patient assessment in the home is usually performed by the RN  The LPN/LVN, when doing private duty in a home, will need to perform daily assessments and maintain necessary documentation  Changes found on assessment should be reported to the RN supervisor As part of an assessment, the nurse asks for information from the patient. This information is a subjective indication of illness perceived by the patient and is called a/an: 1) assessment. 2) symptom. 3) sign. 4) observation All of the following components can be found on the chart except the: 1) face sheet. 2) physician’s order. 3) patient’s history and physical. 4) patient’s nurse assignment. Linda knows as part of her nursing assignment that she is to review and update the nursing care plan on her patients: 1) hourly. 2) every shift. 3) every 24 hours. 4) weekly. 12) Correlate client health issues with priority problem statements. 13) Discuss common problem statements for long-term residents. 14) Plan goals and outcomes for a chosen nursing diagnosis.  Database analyzed for cues that deviate from the norm  Pieces of data are sorted  Related data are grouped or clustered  Missing data are identified  Inferences are made regarding the patient’s problems  Three parts  The client’s problem or potential problem  The causative or related factors  Specific defining characteristics (signs/symptoms)  Medical diagnosis NEVER included  Causes of the problem  Signs are abnormalities that can be verified by repeat examination and are objective data  Symptoms are data the patient has said are occurring that cannot be verified by examination; symptoms are subjective data  Characteristics (signs and symptoms) that must be present for a particular nursing diagnosis to be appropriate for that patient  Supply the evidence that the nursing diagnosis is valid  Problems ranked according to their importance  Physiologic needs for basic survival take precedence (i.e., airway and circulation)  After physiologic needs are met, safety problems take priority  Every nurse must attempt to look at each patient holistically, keeping psychosocial needs in mind while working on physical problems Which one of the following sets of assessment data is most likely to be present with the problem statement “risk for infection”? 1) Fever, dysuria, change in urine concentration, and urinary urgency 2) Abdominal pain, sore mouth, hyperactive bowel sounds, and leukopenia 3) Fatigue, electrocardiographic changes, dependent edema, and activity intolerance 4) Abdominal incision, decreased hemoglobin, and indwelling catheter present  Goal: what is to be achieved by nursing intervention  Short-term goals  Achievable within 7 to 10 days or before discharge  Long-term goals  Take many weeks or months to achieve  Often relate to rehabilitation  Expected outcome: statement of goal patient is to achieve as a result of nursing intervention  Designed to alleviate problems and to achieve expected outcomes  Should include giving medications and performing ordered treatments  Individualized to the patient’s needs  Long-term care  LPN/LVN employed in a long-term care facility begins the care planning process when patient is admitted  The supervising RN determines appropriate nursing diagnoses, reviews the care plan, modifies it as needed, and finalizes it for the chart  Home health care  Nursing diagnosis must include problems identified in the family’s ability to cope with the illness or situation and teaching needs for care of the patient  Care plan encompasses patient and whole family  Planning not complete until plan is documented and is part of patient’s medical record  Plans constructed by LPN/LVNs must be reviewed by the RN before they are placed in the chart  The plan of care should be reviewed and updated once every 24 hours A nurse has established expected outcomes for an assigned patient. The nurse carries out this important activity for the purpose of: 1) evaluating the occurrence of complications. 2) measuring quality of care. 3) measuring the effectiveness of nursing interventions. 4) stopping care when outcomes are met. Implementation and Evaluation 15) Set priorities from a list of problems. 16)Identify factors to consider when implementing the plan of care. 17)List Standard Steps carried out for all nursing procedures.  Implementing care follows assessment, nursing diagnosis, and planning  The phase of the nursing process in which nursing interventions (or orders) are carried out  Change-of-shift report should give clues as to the priority of each action to be implemented  Priorities of care may need to be altered if patient’s condition becomes more acute  Before carrying out specific interventions listed on the plan of care, identify:  Reason for the intervention  Rationale for the intervention  Usual standard of care  Expected outcome  Potential dangers  Some interventions may require an independent nursing action (not requiring a physician’s order)  Check the facility’s policy  Independent Actions Dependent Actions Do not require HCP Do require HCP order order  Administering medications  Client education  Performing wound care  Performing assessment  Initiating IV therapy  Monitoring vital signs  Obtaining lab specimens  Providing basic care  Turning to prevent sores  Assisting with bathing  Some agencies use interdisciplinary care plans, clinical pathways, or care maps to guide care  Interdisciplinary approach to managing patient care  An outgrowth of managed care  Still uses the nursing process  Usually standardized to a medical diagnosis and customized to each patient  Care plan not part of patient’s chart when an interdisciplinary care plan is used; however, nursing process still used  Employees and students expected to perform at standard of care listed in the procedure manual  For efficient time use, consider which interventions for a patient can be combined  Routine care delegated to nursing assistants  Exercise interventions performed by nursing assistants, physical therapy aides, or restorative aides  Medications may be administered by LVNs/LPNs or nursing assistants with certification in medication administration  Nurse performs any invasive or sterile procedure  In home health, family may be implementing the interventions  Nurse making home visits teaches family to:  Administer medications  Change dressings  Perform range-of-motion exercises  Perform treatments  The nurse performs any invasive procedures or procedures where strict sterility is mandatory  Each intervention must be documented in the patient’s chart  Examples: medications administered, dressings changed, vital signs measured  Procedures not documented are considered not performed  Care is documented on flow sheets daily During the implementation of the nursing process: 1) the planned nursing interventions are carried out. 2) reassessment of data is used to determine whether the expected outcomes have been achieved. 3) revision of the nursing care plan is performed. 4) goals are established for the patient. Before Ms. Bricker, LPN, carries out any interventions such as the administration of a medication, she must know: 1) the reason for the intervention. 2) the usual standard of care. 3) the expected outcome. 4) any potential danger. 5) all of the above After Ms. Bricker, LPN, has given her patient medication, she returns later to the patient’s room to evaluate the effectiveness of the medication. She knows that in the evaluation phase of the nursing process: 1) the nursing process has been completed. 2) she doesn’t need to revise the care plan if needs aren’t met. 3) if the expected outcomes are considered met, the nurse’s notes must contain data to support this. 4) there will be no further need for reassessment. 18) Discuss the evaluation process and how it correlates with expected outcomes.  Based on NFLPN Standard 4c—Evaluation  Once interventions have been implemented, they must be evaluated for effectiveness in reaching the patient’s goals or outcomes  Patient should provide feedback about whether the expected outcome has been met  Patient and family should be consulted to find out if the care plan is meeting needs adequately  If expected outcomes are not being met, the interventions are revised  If goals/outcomes are not being reached, the plan must be revised (a continual process)  If goals are reached and the problem is resolved, it is evaluated, signed off in the nurses’ notes as met, and removed from the plan of care  Outcome-based quality improvement to determine whether outcomes are effective  Agency-wide evaluation of care delivered by all departments against standards set for each department  Audits at predetermined intervals  Evaluation goal: continuous quality improvement  RN may construct the initial nursing care plan  If patient admitted to long-term care facility when RN is not available, LPN/LVN may assemble a preliminary nursing care plan that an RN will review and validate as needed the next day  Students, like nurses, must be prepared to care for the patient. A nursing care plan for their assigned patients provides that information. 1) Recognize Cues a) Collect patient data for a database 2) Analyze Cues/Prioritize Hypotheses a) Analyze the database for potential problems b) Choose appropriate problem statements 3) Generate Solutions a) Rank the nursing diagnoses in order of priority b) Plan the care by defining goals and writing expected outcomes c) Plan nursing care by choosing appropriate nursing interventions 4) Take Action a) Implement the nursing interventions 5) Evaluate Outcomes a) Evaluate outcomes of each nursing intervention; determine whether progress toward achieving expected outcomes has been made Debbie, a student nurse, is learning about care plans. She knows all of the following are true regarding care plans except: 1) the family and patient are invited to the care planning. 2) the care plan for the home health patient encompasses the needs and concerns of the family as well as the patient. 3) an LPN is responsible for constructing the care plan. 4) students are required by most instructors to come to the clinical experience with a nursing care plan in hand for assigned patients. Flora, an LPN, is helping her patient understand the side effects of a medication. This is what type of action? 1) Independent 2) Dependent 3) Interdependent 4) Evaluation