The Nursing Process and Critical Thinking: Components, Role, and Documentation

1. Chapter 12 The Nursing Process and Critical Thinking

2. Learning Objectives • Describe the components of the nursing process. • Explain the role of the LPN/LVN in the nursing process. • Describe the proper documentation of the nursing process. • Describe the relationship between the nursing process and the process of documentation. • Explain the relationship between the nursing process and critical thinking. • Describe the characteristics of a critical thinker. • Describe how critical thinking skills are used in clinical practice. • Describe principles of setting priorities for nursing care.

3. Assessment Involves collecting data about the health status of the patient A registered nurse must perform the initial admission assessment for each patient The LVN/LPN collects data through surveillance and monitoring and performs focused nursing assessments

4. Assessment Subjective data Information reported by patient and family in a health history in response to direct questioning or in spontaneous statements Objective data Information that nurse or other members of health care team obtain through observation, physical examination, or diagnostic testing

5. Physical Examination Inspection Purposeful observation of the person as a whole and then systematically from head to toe

6. Figure 12-1

7. Physical Examination Palpation Uses touch to assess various parts of the body and helps to confirm findings that are noted on inspection

8. Figure 12-2

9. Physical Examination Percussion Tapping on the skin to assess the underlying tissues

10. Figure 12-3

11. Figure 12-4

12. Physical Examination Auscultation Listening to sounds produced by the body

13. Figure 12-5

14. Nursing Diagnosis Derived from data gathered during the assessment Nursing diagnosis different from medical diagnosis Focuses on the patient’s physical, psychological, and social responses to a health problem or potential health problem The RN formulates nursing diagnoses; the LVN/LPN is expected to assist with identifying patient needs and implementing plan of care

15. Nursing Diagnosis North American Nursing Diagnosis Association (NANDA International) Develops and revises nursing diagnoses Table 12-1: list of accepted nursing diagnoses Written in a PES format P = problem E = etiology or cause of the problem S = signs and symptoms of the problem

16. Planning Develop a nursing care plan for the patient based on nursing diagnoses Nursing care plans a form of communication with other health care professionals to ensure continuity of care, prevent complications, and provide for health teaching and discharge planning

17. Planning Steps in planning nursing care Determine priorities from the list of nursing diagnoses Set long-term and short-term goals to determine outcomes of care Develop objectives to reach the goals Write nursing orders to direct care to meet the goals Priorities established according to the most immediate needs of the patient

18. Intervention (Implementation) Actual performance of the nursing interventions in the plan of care Includes direct patient care, health teaching, or carrying out ordered medical treatments such as medications or dressing changes Nurses provide care to achieve established goals of care and then communicate the nursing interventions by documentation and report The care plan must be flexible and reflect changes in the patient’s health care needs

19. Evaluation Ongoing process that enables you to determine what progress the patient has made in meeting the goals for care The outcome criteria provide objective measures for determining the effects of care Outcomes compared with expected outcomes of patient care to determine whether the goals have been met, partially met, or not met

20. Evaluation Important in individual care, but also provides data on quality of care in health care institution Quality assurance audits conducted by health care agencies as well as Joint Commission on Accreditation of Healthcare Organizations American Nurses Association Standards of Care used to determine if nurses have carried out the nursing process as documented in patient records

21. Clinical Pathways Standard care plans developed to set daily care priorities, schedule achievement of outcomes, and reduce length of hospital stays Include patient outcomes and timelines for the sequence of interventions Clinical pathways: collaborative and comprehensive; jointly developed by all members of health care team; and cover many aspects of care, not just nursing interventions

22. Concept Maps Visual plans of care that illustrate the relationships between and among pathophysiology, signs and symptoms, nursing diagnoses, and collaborative interventions Used primarily as learning tools to develop comprehensive plans of care

23. Nursing Documentation Helps achieve continuity of care because it provides for communication among caregivers; a record of patient’s progress Provides a legal record of care provided and a means to verify services rendered for insurance payments

24. Nursing Documentation All treatments and care, including medications Procedures performed at the bedside, on the unit, or inside or outside the facility Patient’s reaction to procedures Observations of the patient

25. Nursing Documentation Subjective and objective signs and symptoms experienced by the patient Evidence of changes in the patient’s physical, psychosocial, and spiritual needs and status Any unusual incidents, such as falls or injuries, that occur during the patient’s stay in the health care facility

26. Nursing Documentation Should be factual, current, complete, organized, and accurate Writing should be legible, using proper grammar, punctuation, and spelling Observations stated objectively, describing only what was seen, heard, felt, or smelled Direct quotations from the patient regarding symptoms are appropriate

27. Nursing Documentation Each time an entry is made, sign with your full name and title Use only permanent ink, and make no erasures If you make an error in charting, cross out the entry and write “error” or “mistaken entry,” followed by your initials

28. Documentation Formats Nurses’ notes Pages of narrative recordings containing assessment data, interventions carried out by the nurse, and evaluation data collected Flow sheets May be graphs of vital signs or tables in which nurses may check or initial boxes indicating activities or care provided

29. Documentation Formats Problem-oriented medical record (POMR) Record keeping that focuses on patient problems rather than on medical diagnoses Excellent means of communication among the various disciplines that are providing care The charting is done in a SOAPIER format S—Subjective; O—Objective; A—Assessment; P—Plan; E—Evaluation; R—Revision

30. Critical Thinking Defined as “reflective and reasonable thinking that is focused on deciding what to believe or do” Tools to seek and apply knowledge

31. Relationship of Critical Thinking to the Nursing Process The nursing process is a framework for developing, implementing, and evaluating a plan of care It spells out the patient’s needs and problems, the goals for care, interventions to achieve goals, and how goal achievement will be assessed

32. Relationship of Critical Thinking to the Nursing Process The nursing process does not flow smoothly from one step to the next, but often moves back and forth between steps The nursing process is a sequence of steps that should be based on critical thinking

33. Characteristics of a Critical Thinker Curiosity The desire, not just to know, but to understand how and why, to apply knowledge Systematic thinking Uses an organized approach to problem solving, rather than knee-jerk responses Analytic Applies knowledge from various disciplines, approaches a problem by examining the parts and seeing how they fit together

34. Characteristics of a Critical Thinker Open-minded Willing to consider various alternatives Self-confident Sense of assurance that the problem-solving process produces a good conclusion/plan Maturity Recognition that many variables are at work in patient situations, and sometimes the best plans do not work Truth-seeking Eager to know, asking questions, seeking answers, reevaluates “common knowledge”

35. Critical Thinking Tools Interpretation Clarifying meaning of events, data Analysis Examining ideas, breaking down into components Evaluation Assessing possibilities, opinions, usual practices

36. Critical Thinking Tools Inference Deriving alternatives, drawing conclusions Explanation Presenting arguments for views, decisions; justifying Self-regulation Reconsidering conclusions, recognizing need to make changes