FUNDA LEC:NURSING PROCESS - Curiosity

I. CRITICAL THINKING AND THE NURSING PROCESS DEVELOPIN CRITICAL-THINKING ATTITUDES AND
- Critical Thinking: discipline specific, reflective reasoning SKILLS
process that guides a nurse in generating, implementing, and - Self-assessment
evaluating approaches for dealing with client care and - Tolerating dissonance and ambiguity
professional concerns. - Seeking situations where good thinking is practiced
WAYS HOW THE NURSE USE CRITICAL THINKING - Creating environments to support critical thinking
SKILLS
- Nurses use knowledge from other subjects and fields. II. NURSING PROCESS
- Nurses deal with change in stressful environments. HISTORICAL PERSPECTIVE
- Nurses make important decisions. Lydia Hall
LEVELS OF CRITICAL THINKING - coined the term nursing process
Level 1: Basic - note observation, administration of care and validation
Level 2: Complex Dorothy Johnson
Level 3: Commitment - assessment, decision-making, and nursing action
COMPONENTS OF CRITICAL THINKING Ida Jean Orlando
Specific knowledge Base - client’s behavior, nurse’s reaction and nurses action
Experience Yura and Walsh
Competence - assessment, planning, implementing, and evaluating. (APIE)
Attitudes Knowles
Standards - discover, delve, decide, do, and discriminate
SKILLS IN CRITICAL THINKING American Nurse Association
A. ANALYSIS - started the innovation of the nursing process
- Critical analysis 1973: diagnosis is separate step
- Inductive and deductive reasoning 1980: diagnosis of actual and potential problem are delineated
- Making valid inferences 1991: outcome identification is differentiated assessment,
- Differentiating facts from opinions diagnosis, outcome identification, planning, implementation,
- Evaluating the credibility of information sources and evaluation.
- Clarifying concepts PURPOSES OF THE NURSING PROCESS
- Recognizing opinions - to identify a client’s health status and actual or potential
B. PROBLEM SOLVING health care problems or needs
- Trial and error - to establish plans to meet the identified needs
- Intuition - to deliver specific intervention to meet those needs
- Research process and scientific/ modified scientific method
C. DECISION MAKING CHARACTERISTICS
Steps in decision-making process: - (1) dynamic, (2) client-centered, (3) planned and goal-
- Identify the purpose oriented, (4) universally applicable, (5) problem oriented, (6)
- Set the criteria cognitive process.
- Weight the criteria A. DYNAMIC AND CYCLIC
- Seek alternatives The dynamic nature involves continuous assessment and
- Examine alternatives evaluation of changing client’s responses to nursing
- Project interventions so as to achieve the outcomes.
- Implement B. CLIENT CENTERED
- The plan of care is organized in terms of client problems
- Evaluate the outcome rather than nursing goals.
ATTITUDES THAT FOSTER CRITICAL THINKING - The nurse-client relationship is shaped around the needs of
- Independence the client.
- Fair-mindedness C. PLANNED AND GOA-DIRECTED
- Insight to egocentricity - Interventions are considered according to the nursing
- Intellectual humility diagnoses and are based on scientific principles rather than
- Intellectual courage to challenge the status quo and rituals tradition.
- Integrity D. UNIVERSALLY APPLICABLE
- Perseverance - nursing process can be used with clients of any age, with any
- Confidence medical diagnosis, and at any point on the wellness-illness
continuum.
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E. PROBLEM ORIENTED phases of interview: Orientation phase, Working phase,
- care plans are organized according to client’s problems. Termination Phase
- interventions are carried out to eliminate the problems ORIENTATION
related to any aspect of an individual. - begins with the nurse’s introduction with client which
F. COGNITIVE PROCESS includes the nurse’s name, position, and explanation of
- Nursing process involves the use of intellectual skills in purpose of the interview.
making judgments, decisions and eliminating client’s - nurse client relationship is enhanced by the professionalism
problems and competence conveyed by the nurse’s attitude, manner &
BENEFITS OF THE NURSING PROCESS appearance
CLIENT: WORKING PHASE
- quality care - nurses gather information about the client’s health status.
- continuity of care - nurse use variety of communication strategies such as
- participation of client in their healthcare listening, paraphrasing, focusing, summarizing & clarifying to
NURSES: facilitate communication and ensure that nurse & client clearly
- consistent and systematic nursing education understood each other.
- job satisfaction TERMINATION PHASE
- professional growth - his phase also require skill on the part of the interview.
- avoidance of legal action - The client should be given a clue that the interview is coming
- meeting professional nursing standards to an end.
- meeting standards of accredited hospital - e.g., There are just two more questions, or We will be
HEART OF THE NURSING PROCESS (KSA) finished within 5 to 6 minutes.
- KNOWLEDGE AND SKILLS - This approach also gives the client an opportunity to ask
MANUAL Technical skills questions.
INTELLECTU Critical thinking - terminated in a friendly manner
AL - Careful deliberate, goal-directed ELEMENTS FOR EFFECTIVE INTERVIEW:
- Make decisions - clear goal, aware about background of the client, self-
- Good habits of inquiry introduction, choose closure, maintain rapport, confidentiality,
- Check evidence recovery, closure
- Keeping an open mind planning: time, place, seating arrangement, distance,
- Avoid jumping into conclusions language.
INTERPERSO To establish positive interpersonal TYPES OF INTERVIEW TECHNIQUE
NAL relationship with clients, co-workers 1.OPEN ENDED QUESTIONS
ATTITUDES - prompts clients to describe a situation in more than one or
- being able to care understanding ourselves two words.
- to be more able to understand others - These questions give a chance to client to speak freely.
- to be more objective, and non-judgmental e.g., What do you know about your condition? How do you
feel in hospital?
III. PHASES OF NURSING PROCESS 2. CLOSE ENDED QUESTIONS
1. ASSESSMENT - prompts client to give answer in only one or more words
METHOD OF DATA COLLECTION e.g., Do you have pain? How many time you go to the toilet?
- (1) observation, (2) interview technique, (3) physical NEUTRAL QUESTIONS
examination, (4) laboratory tests, (5) review of the records, - how do you feel about that?
books, and related literature LEADING QUESTIONS
1. OBSERVATION - you are stressed about surgery tomorrow, aren't you?
- observing is conscious, deliberate skill that is developed 3. PHYSICAL EXAMINATION
through effort and with an organized approach. Eg: Using the - technique: IPPA
senses to observe client data - cephalocaudal approach, screening examination, review of
- Methods observation: vision, smell, touch, hearing the systems
- Aspects of data: Noticing data, Selecting, organizing, and VALIDATION OF DATA
interpreting the data. - data validation to be done to ensure accuracy
2. INTERVIEW TECHNIQUE - validation of collected data involves comparing the data with
- It is an organized conversation with the client or family other sources
members to obtain the current health information regarding ORGANIZATION OF DATA
patient. - Clustering of Data and Arrangement: in a systematic and
logical order which gives clue for nursing diagnosis
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 - Conceptual models or frame works -official organization responsible for developing system of
- Nursing models or framework naming & classifying nursing diagnoses
- Gordon's functional health pattern - Diagnostic label is often called a “NANDA.”
- Orem’s self-care model - Each NANDA describes the essence of the problem in as few
- Roy’s adaptation model words as possible
- Wellness model - example:
- Non nursing models NANDA: Impaired Physical Mobility
- Body system model NANDA Definition: state in which a person experiences or is
- Maslow’s hierarchy of needsb at risk of experiencing limitation of physical movement but is
- e.g., anger is a cue for the diagnosis for anxiety, and not immobile.
fear.
TYPES OF NURSING DIAGNOSES
RECORDING OF DATA 1. Actual nursing diagnoses: patient has problem
- Documentation should be concise, thorough, and accurate 2. Risk diagnoses: patient is at risk for developing the
- Documentation depends upon the institutional policy problem (Either begins with “Risk for” or the definition will
- It is descriptive in nature include “is at risk for”)
3. Wellness diagnoses: patient functioning effectively but
2. DIAGNOSIS desires higher level of wellness
1.Gathering Data 4. Possible diagnoses, Syndrome diagnoses, and Collaborative
2.Validating Data problems. (Others that you do not need to know)
3.Organizing Data
4.Identify Data COMPONENTS OF NURSING DIAGNOSIS
5.Reporting & Recording Data 1. PROBLEM (LABEL)
- analysis and synthesis of data diagnosis - there are word that have been added to some NANDA label
- “Nurse are responsible and accountable for diagnosing actual to give additional meaning
and potential health problem and initiating action to ensure - e.g. altered, impaired, decrease, ineffective, acute, chronic,
appropriate and finely treatment” knowledge deficit, effective breathing pattern
- nursing diagnosis has two meanings: 2. ETIOLOGY
- Nursing diagnosis is a label that describes the patient’s A. Related Factors
response to an actual or potential health problem. - factors that contributed to the development of patient’s
- Nursing diagnosis is an action: the process of analyzing problem (nursing dx)
assessment data to arrive at a nursing diagnosis. - Is a relationship rather than direct cause & effect (is ‘related
MEDICAL NURSING to’ rather than ‘caused by’)
- Describes a disease or - Describes pt’s response to - Only one of these factors (risk or related) needs to be present
pathology a health problem to justify use of the nursing dx.
- Conditions MD treats - Situations RNs can treat B. Risk Factors
- MD cares for a pt. - Nursing dx: describe pt’s - factors that increase the possibility of the patient developing
- Congestive Heart Failure response to CHF a problem.
(CHF) treats pathology with - such as: Anxiety Activity
3. DEFINING CHARACTERISTIC
meds, oxygen, diet & fluid Intolerance, Impaired
-These are the signs & symptoms that validate that an actual
restriction Peripheral Tissue Perfusion,
nursing diagnosis is present.
Powerlessnes
1.Major: at least one must be present to use the nursing
diagnosis
NURSING DIAGNOSIS: THE ACTION
2.Minor: may not be present, but if it is, helps to validate
- RN review assessment data to identify patterns.
selecting the nursing diagnosis
- subjective and objective “cues” are organized into groups
- Defining characteristics are not present in Risk dx because
that seem to fit together and indicate actual or potential
signs & symptoms don’t exist if the problem hasn’t happened.
problem (nursing dx)
- RN makes an educated hunch about which nursing diagnoses
might fight the cue cluster ACTUAL DIAGNOSTIC STATEMENT THREE-PART
- review the selected nursing diagnoses to decide which is FORMAT
most accurate 1. NANDA label
NURSING DIAGNOSIS: THE LABEL 2. Related factors (follows NANDA & linked by the words
- North American Nursing Diagnosis Association (NANDA) “related to”)
3. Defining characteristics (follows related factors & linked by
the words “as manifested)
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- example: - Consider something that is very important to the client e
“Impaired Physical Mobility r/t muscle weakness AMB x.Pain, anxiety
limited ROM” - Clients unstable condition
- Resources
RISK DIAGNOSTIC STATEMENT TWO-PART FORMAT - Actual problems take precedence over potential concerns.
1. NANDA label - Attend to the client before the equipment
2. Risk factors (follows NANDA label and is linked by the
words related to) SETTING PRIORITIES
Example: Risk for Impaired Physical Mobility r/t full leg cast - Priority setting is the process of establishing a preferential
sequence for addressing nursing diagnosis and interventions
CLARIFYING THE RELATED FACTORS PART OF THE - Nurses use frequently use Maslow’s hierarchy of needs when
DIAGNOSTIC STATEMENT setting priorities
- You will often need to add words to the ‘related to’ portion
of an actual or a risk diagnostic statement to clarify the origin CLASSIFICATIONS
of the problem 1. High priority
- These words always follow the ‘related to’ and are linked - potentially life-threatening and required immediate action
with the words ‘secondary to’ (2°) 2. Medium priority
- This is the only way a medical diagnosis can ever be inserted - problems that can result to unhealthy consequences but not
into a nursing dx. life-threatening
- example: impaired Physical Mobility r/t muscle rigidity and 3. Low priority
tremors secondary to (2°) Parkinson’s Disease AMB limited - problems that can be resolve easily with minimal
ROM and compromised ability to move purposefully. interventions
WELLNESS DIAGNOSTIC STATEMENT
- Used when pt doesn’t have a health problem but can attain
higher level of health FACTORS WHEN ASSIGNING PRIORITIES
- Client’s health values and beliefs
- Is a one-part statement consisting only of the NANDA:
- Client’s priorities
- Example: Readiness for Enhanced Parenting, Readiness for
Enhanced Family Processes, Readiness for Enhanced Spiritual - Resources available to the nurse and client
Well- Being. - Urgency of the health problem
- Medical treatment plan
3. PLANNING
- Planning is a deliberative, systematic phase of the nursing ESTABLISHING CLIENT GOALS /DESIRED OUTCOME
process that involves decision making and problem solving. Goals or Desired Outcomes
- Formulating client goals and designing the nursing - Nurses hope to achieve by implementing the nursing
interventions required to prevent, reduce or eliminate the interventions
client’s health problems - Expected outcome
- Predicted outcome
PURPOSE OF PLANNING - Outcome criterion
- to identify the client’s goal and appropriate nursing - Objective
interventions - Goals are broad statement of client status
- to direct client care activities - Desired outcomes as more specific, observable criteria used
- to promote continuity of care to evaluate whether the goals have been met.
- to focus charting requirements
- to allow for delegation of specific activities PURPOSES OF DESIRED GOALS AND OUTCOMES
- Provide direction for planning nursing interventions
TYPES OF PLANNING - Serve as a criterion for evaluating client progress
1. Initial Planning: Admission assessment, initial - Enable the client and nurses to determine when the problem
comprehensive plan of car has been resolved
2. Ongoing Planning: nurses who work with the client - Help to motivate the client and nurse by providing a sense of
3. Discharge Planning: Anticipating and planning for needs achievement
after discharge - nursing goal has two types: 1) Short-term and 2) Long
term.
ESTABLISHING PRIORITIES INCLUDES
- Life- threatening situations CRITERIA FOR FORMULATE NURSING GOALS
- Use of the CAB principles Maslow’s hierarchy of needs (SMART)
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- Specific
- Measurable
- Attainable
- Realistic
- Time-Bound

COMPONENTS OF GOAL
1. Subject: a noun, is the client, any part of client or some
attribute to client
2. Verb: the verbs specify an action the client is to perform
Eg: show, walk and drink.
3. Condition or modifiers: are added to the verb to explain
the circumstances under which the behavior is to be
performed. Eg: walks with the help of cane
4. Criterion of desired performance: the criterion indicates
the standard by which performance is evaluated
Eg: walk one block per day.

GUIDELINES FOR WRITING GOALS AND OUTCOMES

- client-centered
- Singular goal and outcome
- Observable
- Measurable
- Realistic
-Time limited
- Mutual factors
- Compatible
- Make sure client considers the goals important and value.
4. EVALUATION
- purpose: to determine the client’s response with regards to
the interventions rendered
ACTIVITIES UNDER EVALUATION
1. Collecting data related to the outcome
2. Comparing data with outcomes
3. Relating nursing activities to outcome
4. Drawing conclusions about the problem status
5. Continuing, modifying, or terminating the nursing care plan
TYPES OF EVALUATION
1. ONGOING EVALUATION
- performed while implementing, immediately after an
intervention and at each patient contact; allow you to judge
patient progress toward goal
2. INTERMITTENT EVALUATION
- performed at specific times; allow you to judge patient
progress toward goal
3. TERMINAL EVALUATION
- describes the client's health status and progress toward goals
at the time of discharge

FOUR POSSIBLE JUDGMENTS OF THE OUTCOME

1. Completely met/ goal met
2. Partially met
3. Completely unmet/ goal not met
4. New problems or nursing diagnoses have developed

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