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Critical Thinking: The Foundation for Nursing Process
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Intuition:
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Stack #153401
Critical Thinking
| Question | Answer |
|---|---|
| Critical Thinking: The Foundation for Nursing Process | Use a systematic way to think: Identify the Problem, Collect Data, Form a concept about the relationship between the data and the problem, implement a plan of action, analyze the effect of action, evaluate the plan of action |
| Intuition: | comes after years of practice, can indicate a problem before clinical signs are evident |
| Blended Skills | Cognitive, Technical, Interpersonal, Ethical |
| Cognitive Skills | Gives scientific rationale and ability for select "best-match" interventions |
| Technical Skills | Allows Competent, comfortable use of technical equipment |
| Interpersonal Skills | Affirms worth of clients, elicits client goals and strengths, allows for collaboration with healthcare team |
| Ethical Skills | allows for client centered practice which is accountable and consistent with standards of practice |
| Analysis | Examine all elements, Think through alternative strategies, Identify options in a patient situation, Prioritize |
| Reflection | Involves self evaluation -- How you handle a situation, what you would change next time; Connection between theory and nursing practice; demonstrate through sharing in post conference and writing |
| Attributes of Critical Thinkers | Adequate knowledge; purposeful, disciplined; independent thinker, courageous; fair, humble; personal integrity; curious, creative; confident |
| Clinical Judgment | Critical thinking supports clinical judgment: -- identifies and challenges assumptions; considers wht is important in a situation; explores alternatives; applies logic and reasoning, makes an informed decision; |
| Clinical Judgment is required | in nursing practice |
| Critical Thinking/Clinical Judgment | Purposeful, informed, outcome-focused; driven by patient, family and community needs; judgments based on evidence; uses both intuition and logic; guided by professional standards; ongoing re-evaluation and striving for improvement |
| Nursing Process | Framework for Nursing practice; framework for critical thinking; determine client needs; intervene to resolve or meet the need; determine whether need is met |
| Five Steps of Nursing Process | Assessing; Diagnosing; Planning; Implementing; Evaluating |
| Assessment: Gathering data | Subjective; Objective |
| Assessment: Sources of data | Patient, family, significant others; Records; Health care Team |
| Data Clustering | Human response to health problem; Cohort data/body systems |
| Example #1 of Data Clustering | RR 32, accessory muscles, "I can't get enough air!" diminished breathing sounds bilaterally |
| Example #2 of Data Clustering | Abdominal incision is red and has some bloody draining, T 100.8, P 92, BP 112/84 |
| Analysis/Diagnosis Phase | Analyze: interpret, validate and clustered data; select diagnosis from a list developed by NANDA |
| Example of Nursing Diagnosis | ineffective breathing pattern; shortness of breath; elevated respiratory rate (34); Use of accessory muscles; Aleration of O2, CO2 ratio |
| Nursing Diagnosis | Clinical judgment about individual, family or community responses to actual or potential health problems; Provides basis for selection of nursing interventions to achieve outcomes; Common language for nurse communication |
| Part 1 of Nursing Diagnosis: | Human Response |
| Part 2 of Nursing Diagnosis: | Related factors |
| Part 3 of Nursing Diagnosis: | Defining characteristics: evidence that supports the conslusion of a problem |
| Types of Nursing Diagnosis | Actual, Risk, Possible, Wellness |
| Actual Diagnosis | has a health care need/problem |
| Risk Diagnosis | High potential for developing a health care need/problem |
| Possible Diagnosis | suspicion that there could be problem under the right circumstances but not enough data to confirm it |
| Wellness Diagnosis | Transition to a higher level of functioning building on client's strengths |
| Example of Actual Diagnosis | Assessment data: No stool in 5 days, low fiber diet; Human Response (NANDA) constipatiaon; Related to: r/t low fiber diet; As evidenced by: a.e.b. no stool in 5 days; Nursing Dx: Constipation r/t low fiber diet a.e.b. no stool in 5 days |
| Example of Risk Diagnosis | Assessment data: Head injury, poor gag reflex, oriented x1; Problem/human response: potential for aspirataion; Related to: diminished gag reflex; Nursing Dx: Potential for aspiration r/t diminished gag reflex |
| Example of Possible Diagnosis | Assesment data: Post-operaive patient with mild SOB; Hman response/nursing diagnosis: Possible ineffective airway clearance; Possible alteration in gas exchange |
| Nursing Diagnosis is: | Actual, Potential, Possible & Wellness |
| Actual Nursing Diagnosis | Human Response (NANDA), etilogy, and supporting data |
| Potential Nursing Diagnosis | Human Response (NANDA) and etiology |
| Possible Nursing Diagnosis | Human Response (NANDA) |
| Writing Nursing Diagnoses | Write in Terms of the client response, not the nursing need; Avoid use of value judgments; Two parts of the diagnosis should not mean the same thing; Avoid reversing the parts; Write the problem and related factors in terms that can be changed; State the |
| Planning Phase | Establish client goals to prevent, reduce or resolve the problems identified in the nursing diagnosis; Identify nursing interventions/actions that will assist the client to achieve their goals |
| Elements of the Planning Phase | Priority setting; Goals and/or outcomes; Nursing interventions; Written nursing care plan; Ongoing |
| What Determines the Priority Setting? | Maslow's Heirachy |
| Priority Setting | What is most important to do, Often what must be accomplished first; How do we determine priorities? Who determines Priorities? Actual vs potential problems |
| Nursing Diagnosis: A Blueprint for Care | Outcome Interventions Evaluation: 1. Problem; 2. Related to (r/t); 3. Defining characteristic |
| Mutual Goals | What we (the nurse and the patient) want to achieve |
| Short-Term Goals | realistic, measrable and able to achieve |
| Long-Term Goals | Later e.g. end of shift or by discharge |
| Is there a relationship between Long and Short Term Goals? | Yes, they have to be related |
| Purpose of Goals | Select nursing actions; evaluate patient's progress |
| Characteristics of Goals | Be measurable, not general or vague; Be objective, not subjective; be realistic, be attainable; Complement the nursing diagnosis; Have a time frame |
| Guidelines for Writing Goals/Outcomes | Subject, Verb, Criteria, Common verbs |
| Subject of Goals/Outcomes | Usually the patient, family or community |
| Verb of Goals/Outcomes | Action to be performed |
| Criteria for Writing Goals/Outcomes | Expected patient behavior in observable, measurable terms |
| Common Verbs for Goals/Outcomes | Define, Identify, List, state, describe, verbalize, select, demonstrate, explain, design, prepare, choose, apply |
| Nursing Interventions | Activities performed to meet the client's needs and reach teh client's goals; Nursing interventions are identified in the planning stage; Nursing interventions are performed in the implementation stage of the nursing process; Consist of nursing orders |
| Nursing orders | the written instructions for performing the nursing interventions; Continuity of care; nursing orders: nursing interventions = nursing actions |
| Difference between Expected Outcome and Nursing Order | EO: Patient Behaviors; NO: Nursing activities or actions |
| Independent Nursing Actions | Positioning, Vital signs monitoring, fluids, moniiring I & O, Assisting/providing in Self Cre, Assuring rest/sleep, Nutritional monitoring, Health education, Reassurance/support |
| Implementation Phase | Actions are performed to carry out the plan of care; includes all aspects of care, assist patients to achieve health goals, promote wellness, prevention of disease and restoration of health, facilitate coping with altered functioning |
| Carrying Out The Plan of Care | Implement the independent, dependent and collaborative nursing orders; Continual assessment; Accountable for: evidence based practice, standards of care: HCC, agency and professional |
| Documentation of Care | Nursing interventions; Patient responses |
| Evaluation | Measure Outcomes; Identify Contributing Factors, Document Evaluative Statement; Decide whether to terminate, continue or modify the plan of care |
| Document Evaluative Statement | Did the actions work? Were they effective? Did the patient achieve expected outcome? |
| Measure outcomes | Collect evaluative data; Compare expected outcomes to actual |
| Human Response | Represents pattern of related cues; The problem; Nanda |
| Related factors | Etiology or cause of the problem; related to (r/t) |
| Defining characteristics: evidence that supports the conslusion of a problem | Assessment data or signs & symptoms; As evidenced by (a.e.b.) |
Created by:
howardccnurs
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