Chapter 33 Introduction to the Nursing Process

1. Chapter 33Introduction to the Nursing Process

2. Nursing Care • A primary goal of nursing • To help individuals meet their basic and higher-level needs • Nurses provide care to clients by combining scientific problem-solving methods with critical thinking skills to provide care through the nursing process.

3. *Problem-Solving • Problem-solving • The basic skill of identifying a problem and taking steps to resolve it • Trial-and-error problem-solving • An experimental approach • Experimenter does not have sufficient information to anticipate results. • Scientific problem-solving

4. *Scientific Problem-Solving • Seven steps: • Identify the problem. • Gather information relative to the problem. • Formulate hypotheses; choose preferred solution. • Plan action to test suggested solution. • Experiment and observe the results. • Draw conclusions; understand what the results mean. • Evaluate the solution.

5. Critical Thinking • A complicated mix of inquiry, knowledge, intuition, logic, experience, and common sense is called critical thinking. • It enables you to grasp the meaning of multiple clues and to find quick answers when facing difficult problems. • It is an important nursing strategy for problem-solving.

6. Critical Thinking and Problem-Solving • Critical thinking has some characteristics that are important for solving problems in healthcare. • Examine facts and compare these facts with information already available, thereby being actively curious and critiquing ideas for reasonableness. • *Form own beliefs or ideas rather than accepting the thoughts or ideas of others and become an open-minded person, flexible to alternatives.

7. The Nursing Process • The nursing process is a framework of scientific problem-solving combined with critical thinking skills. • It directs the nurse and client as they together: • Determine the need for nursing care • Plan and implement the care • Evaluate the results • Nursing care plan (NCP) • Guidelines derived on the basis of the nursing process to ensure consistency among nursing staff.

8. **The Nursing Process

9. *Nursing Assessment • The systematic and continuous collection of data • Identify priorities • Collect data • Update database

10. *Nursing Diagnosis • The statement (or label) of the client’s actual or potential problem • Recognize and label significant data. • Recognize patterns or clusters. • Identify strengths and problems. • Reach conclusions. • Validate observations. • Write diagnostic statements.

11. Planning • Development of goals for care and possible activities to meet them • Identify priorities. • Establish expected outcomes or goals. • Anticipate nursing interventions. • Prepare to document specific actions that will reach outcomes/goals by stating specific timeline for the plan. • *Formulate tentative solution to problem

12. *Implementation • The giving of actual nursing care • Take actions that are necessary to achieve goals. • Adjust actions as conditions change. • Monitor and report results of assessment, goals, and interventions to other healthcare team members.

13. *Evaluation • The measurement of the effectiveness of nursing care • Analyze the client’s responses to the problem, goals, and actions. • Identify factors that contributed to success or failure of the NCP’s outcomes or goals. • Re-evaluate and reassess. • Continue with nursing process in a cyclic manner.

14. Characteristics of the Nursing Process • *Systematic • The nurse follows specific, orderly, and logical steps based on the client’s most important and often most vital needs; prioritization or prioritizing. • Client-oriented • Client needs are identified. • Focus on meeting individualized client needs, rather than on performing specific skills.

15. Characteristics of the Nursing Process (cont’d) • Goal-oriented: Goals, objectives, or expected outcomes are established as an early part of the nursing process. • Short-term goals • Measurable outcomes that can be achieved in hours, days, or weeks, depending on the individual problem • Long-term goals • Provide guidance for the days, weeks, or months during and after the time a client is seen by a health provider

16. Characteristics of the Nursing Process (cont’d) • Continuous • Because the life and health of individuals change, reassessment of the client’s needs is done frequently. The existing nursing process must be redesigned spontaneously to fit the most current and highest priority needs. • Dynamic • Although it contains definite steps, these steps often overlap; ever-changing.

17. Nursing Process and Quality Care • The nursing process is an important tool for providing measurable and observable evidence indicating the effectiveness of nursing care given in any setting. • Licensed nurses are responsible, or accountable, for their actions. • Because all the nurses providing care for a client refer to the same care plan, consistency of care is ensured. • If goals are not being met, a re-evaluation will indicate what further needs must be identified.