Chapter 1 Overview of Nursing Process, Clinical Reasoning, and Nursing Practice Today

1. Chapter 1Overview of Nursing Process, Clinical Reasoning, and Nursing Practice Today

2. Question • Is the following statement true or false? • Nursing process is a linear process.

3. Answer • False • Rationale: The nursing process is a cycle rather than a linear process.

4. Nursing Process • Foundation for clinical reasoning • Required by national practice standards • Tested on NCLEX • First tool “to think like a nurse”

5. Nursing Process (cont.) • Cycle • Not a linear process • Purposeful

6. Question • What are the phases of the nursing process? • 1. Assessment • 2. Diagnosis • 3. Planning • 4. Implementation • 5. Evaluation • A. 1, 2, and 4 • B. 1, 3, 4, and 5 • C. 1, 2, 3, and 4 • D. 1, 2, 3, 4, and 5

7. Answer • D. 1, 2, 3, 4, and 5 • Rationale: The five phases of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.

8. Phases in Nursing Process • Assessment • Diagnosis • Planning • Implementation • Evaluation

9. Assessment • Collect and record all the information to: • Predict, detect, prevent, and manage actual and potential health problems • Promote optimum health, independence, and well-being • Clarify expected outcomes (results)

10. Diagnosis • Analyze the data you gathered, draw conclusion, and determine whether there are: • Risks for safety or infection transmission (deal with these immediately) • Signs or symptoms that need evaluation by a more qualified professional (report these immediately) • Actual and potential health problems requiring nursing or medical management

11. Diagnosis (cont.) • Risk factors requiring nursing or medical management • Issues that aren’t quite clear, but require further investigation • Learning needs that must be addressed • Patient resources, strengths, and use of healthy behaviors • Health states that are satisfactory but could be improved

12. Planning • Clarify expected outcomes (results), set priorities, and determine interventions (nursing actions). The interventions are designed to: • Detect, prevent, and manage health problems and risk factors • Promote optimum function, independence, and sense of well-being • Achieve the expected outcomes safely and efficiently

13. Implementation • Put the plan into action. • Assess the patient to determine current status—decide whether the patient is ready and the interventions are still appropriate. • Perform the interventions (nursing actions). • Reassess the patient to determine end results (outcomes). • Make immediate changes as needed. • Chart nursing actions and patient responses.

14. Evaluation • Do a comprehensive patient assessment to decide whether expected outcomes have been met or whether new problems have emerged. • Decide whether to modify or terminate the plan. • Plan for ongoing continuous assessment and improvement.

15. Keys Things to Remember • Nursing process phases • Overlap • Interrelated

16. Accuracy of Nursing Process Steps • Good communication skills • Factual • Relevant • Comprehensive assessment data

17. Nursing Process and Nursing Activities • Formal care planning • Documentation • Guide for thinking at the point of care every day

18. Question • Is the following statement true or false? • Critical thinking is a broad term that includes clinical reasoning.

19. Answer • True • Rationale: The terms critical thinking and clinical reasoning are often used interchangeably. Critical thinking is a broad term that includes clinical reasoning.

20. Critical Thinking and Clinical Reasoning • Often used interchangeably • Critical thinking is a broad term that includes clinical reasoning.

21. Clinical Reasoning • Specific term • Assessment and management of patient problems at the point of care

22. Critical Thinking • Promoting teamwork and streamlining work flow • Reasoning other issues, besides assessment, and management of patient problems

23. Complements Other Health Care Workers • Focusing on both medical problems and on the impact of medical problems and treatment plans on patients’ lives • Aims to promote health • Maximizing independence • Sense of well-being • Ability to function regardless of presence of illness or disability

24. Application of Nursing Process • Requires application • National and state laws • Local policies and procedures • Follows ethics codes and principles. • Applies a code of conduct.

25. Competent in the Use of Nursing Process • Develop critical thinking behaviors • Strong interpersonal and technical skills • Be willing and able to care