Microsoft PowerPoint Nursing Process Overview PDF

Nursing Process Overview
Fall, 2010
Julie Waddell
Nursing Process Overview
Objectives
1. Explain ways in which nurses use
critical thinking.
2. Identify the steps of the nursing
process.
3. Discuss the importance of the nursing
process as it relates to client care
4. Relate how nurses implement each
step of the nursing process.
Questions to Ponder…
l What is Critical Thinking?
l Why is Critical Thinking Important to Nurses?
l What are the Different Kinds of Nursing Knowledge?
l What are the Five Major Categories of Critical
Thinking?
l What is the Nursing Process?
l What are the components of the Nursing Process?
l What is FullSpectrum Nursing?
What Is Critical Thinking?
A combination of:
l Reasoned thinking
l Openness to alternatives
l Ability to reflect
l A desire to seek truth
What is Critical Thinking?
l “…reasonable reflective thinking that is
focused on deciding what to believe or do”
(Ennis, 2000)
l Process through which nurses analyze and
make sense of situations in order to make
sound clinical decisions.
l “the art of thinking about your thinking while
you are thinking in order to make your
thinking better…” (Paul, 1988)
Components of Critical Thinking
l Skills: Cognitive (intellectual) activities and processes used in
problem solving and decision making.
1. Gather information
2. Identify problems
3. Recognize gaps in own knowledge
4. Listening, reading
5. Organizing information
6., 7., 8.,…visualizing, exploring, evaluating credibility
l Attitudes: NOT the same and intellectual skills…Attitudes are
like feelings and traits of mind
1. Independent thinking
2. Intellectual curiosity
3. Intellectual humility
4. Intellectual empathy
5. Intellectual courage
6. Intellectual perseverance
7. Fairmindedness
Critical Thinkers Ask Questions.
Inquiring Minds WANT to KNOW!
l What am I taking for granted?
l Did I explore all points of view?
l Do I understand the question?
l What information do I need?
l Do I need to report anything?
l What complications should I anticipate?
l Which is my highest priority?
l Are there ethical or cultural issues I should
consider?
Why Is Critical Thinking
Important for Nurses ?
l Nurses deal with complex situations
l Our clients are unique
l Nurses apply knowledge to provide holistic
care
l Nursing is an applied discipline
l Nursing uses knowledge from other fields
l Nursing is fastpaced
Models for Complex Thinking
Table 21 Fundamentals pg.28
l Nurses must use COMPLEX THINKINKING
in every aspect of their work:
l Problem solving—identifying problem and
finding solution
l Decision making—choosing the best action to
take to produce desirable outcome
l Clinical reasoning—Reflective (asking yourself),
creative thinking about care, logical thinking.
Different Kinds of Nursing
Knowledge
l Theoretical
l Practical
l Personal
l Ethical
Five Major Categories of
Critical Thinking
l Contextual awareness
l Inquiry
l Considering alternatives
l Examining assumptions
l Reflecting critically
What Is the Nursing Process?
l Definition:
A systematic problemsolving process that
guides all nursing actions
l Purpose:
To help the nurse provide goaldirected,
clientcentered care
What Are the Phases of the Nursing
Process ? (Wilkinson, 2001)
l Assessment
l Diagnosis
l Planning Outcomes
l Planning Interventions
l Implementation
l Evaluation
Nursing Process
Critical Thinking and
Problem Solving
l The nurse uses the nursing process to
identify and make decisions about client
needs.
l The nursing process is a systematic and
scientificallybased process.
l The process requires the use of many
cognitive and psychomotor skills
Nursing Process and Critical
Thinking
What are the Phases of the
Nursing Process?
l Assessment:
l First phase; Data gathering
l Diagnosis:
l Second phase; Identify client’s health needs
What are the Phases of the
Nursing Process? (cont.)
l Planning Outcomes:
l Decide goals you want to achieve with your
nursing activities.
l Planning Interventions:
l Decide interventions to help client achieve stated
goals.
What Are the Phases of the
Nursing Process? (cont.)
l Implementation:
Action phase; when you carry out or delegate
actions you previously planned
l Evaluation:
Final phase; judge whether your actions have
successfully treated or prevented the client’s
health problems
How Is the Nursing Process
Related to Critical Thinking?
l Nursing is a problemsolving process that
uses many individual critical thinking skills
What Is FullSpectrum Nursing?
Definition:
A unique blend of thinking and doing that
translates caring into action.
What Are the Model Concepts?
l Critical Thinking
l Nursing Knowledge
l Nursing Process
l Patient Situation
Full Spectrum Nursing Model
Meet the Garcias Exercise
l Fundamentals Text Vol. 2
The Four Critical Thinking Skills:
l Reading
l Listening
l Observing
l Analyzing
To Improve Critical Reading
l Highlight the main ideas as you read. If most of
the text is highlighted you are not reading
critically.
l Join a study group and see if your main idea is
the same as fellow group member’s.
l Dialogue with yourself to identify the main idea
of your reading.
l Try to state the main idea in your own words
To Improve Critical Listening
l Restate the points made in a discussion with
others to see if you understand them.
l Focus on what a speaker is saying and listen
for key points.
l While listening, make note of anything you
find confusing, and ask about it later.
To Improve Critical Observing
l Remove any restrictions in your mind.
l Eliminate or decrease any distraction.
l Ask yourself if you understand the most
important points?
l Create new ways of looking at situations
l Always look from outside the situation .
To Improve Critical Analyzing
l Maintain clear and accurate logic.
l Take all details into consideration.
l Use systematic and scientificallybased
process.
l Use both cognitive and psychomotor skills.
Barriers to Creative Thinking
l Resistance to change, rigid mindset,
practice guided by tradition, habit, routines
l Stereotypical perceptions of clients
l Fear of making mistakes
l Unwillingness to take risks or look for
alternative strategies
l Decision making without sufficient data or
supported by rationale
l Failure to evaluate effectiveness of nursing
actions
Critical Thinking and Creativity
l Critical thinkers = creative thinkers
l Question the status quo.
l Search for new and practical strategies for
improvement.
l Groupthink: a major block to creativity
The Nursing Process
l A way of thinking
l A way of doing
l Involves 6 basic
steps:
1. Assessment
2. Diagnosis/Problem
Identification
3. Planning Goal/Outcome
Planning Interventions
4.Implementation
5. Evaluation
Critical Thinking Applied to
Nursing
l Critical thinking
l Learned skill
l Vital tool
l Nurses need to have a questioning
attitude in every phase of the nursing
process.
Components of the Nursing
Process
Using the Nursing Process
page 30 Brunner and Suddarth
Step 1: Assessment
l Data collection
l Validation of data
l Organization of data
l Pattern identification
l Initial inferences
l Recording or reporting data (Health History
and Physical Assessment)
Step 2: Diagnosis/Problem
Identification
l Analysis and synthesis of data—determine the pt.’s
need for nursing care.
l Formulation of nursing diagnoses—from an
accepted list approved by NANDA (North
American Nursing Diagnosis Association)
l Actual problems
l Potential problems
Collaborative problems—require collaborative interventions with
MD and other members of the health care team. (B&S pg. 40
Figure 32)
Step 3: Planning Outcome/Goal
and Planning Interventions
l Prioritize nursing diagnoses.
l Identify and write outcomes and goals.
l Develop specific interventions.
l Record plan.
l Communicate to other members of health
care team
Step 4: Implementation
l Executing/carry out the plan
l Necessary skills
l Continual assessment
l Psychomotor
l Interpersonal
l Critical thinking
l Communication: writing, reporting, revising
ALL interventions are pt.focused and outcome
directed. They should be carried out with
compassion, confidence, and a willingness to
accept and understand the pt.’s responses.
Step 5: Evaluation
l Evaluate the goals.
l Met?
l Not met?
l Partially met?
l Reassess.
l Make necessary changes.
l Evaluation is a continual process.
Nursing Process
l Relationship to
Nursing – steps
interrelated but separate.
l Background – 1955, 1 st
described nursing as a
process…evolved to what
it is today
l Purpose – basis of
nursing practice, guides
care to clients
Organization: The Steps of the
Nursing Process
l Assessment Getting the Facts
l Diagnosis What is the problem?
l Planning Interventions and Goal
Writing/Outcome Identification What do
you want to happen? How can you make it
happen?
l Implementation Doing, Delegating,
Documenting
l Evaluation Did it work?
Benefits of the Nursing Process
l Client
l continuity of care
l prevention of omission
and duplication
l individualized care
l increased client
participation
Benefits of the Nursing Process
l Nurse
l Job satisfaction
l continual learning
l increased self
confidence
l staffing assignments
l standards of practice
l Profession
l promotes collaboration
l helps people to
understand what nurses
do
Sample Test Question
The RN has been assigned a 66year old female patient. Her
diagnosis is congestive heart failure. Her blood pressure
during the previous shift was in the normal range. The UAP
reports a very high blood pressure reading. Which of the
following demonstrates the use of criticalthinking skills:
A. RN checks her blood pressure and considers possible causes if it
remains elevated.
B. RN has the UAP record the blood pressure and he plans to discuss the
case with his charge nurse later in the shift.
C. RN calls the doctor immediately to report these findings.
D. RN instructs the UAP to check the blood pressure in an hour and to
notify him immediately if it remains elevated.
Rationale
l Critical thinkers are inquisitive about information and
facts. They wonder “WHY?” The patient had a normal
BP and it is now elevated. Critical thinkers validate
facts. RN wishes to validate the UAP’s data to be
certain it is correct before trying to figure out causes for
the problem. The RN wondered, “Why is the BP
elevated? Is the reading accurate? Or is something
wrong?” Only in (A) does the nurse demonstrate these
skills. Response (D) might have been a second choice.
If the UAP took the BP an hour later and it had returned
to normal there might be no cause for concern. If the BP
was extremely high though, the RN would not want to
wait another hour to be certain nothing was wrong. (B)
and (C) are wrong.

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