Nursing Process:Foundations Introduction to Patient Care and Critical Thinking

Foundations of Thoughtful Person-Centered Practice

• Person-centered care is the core of professional nursing practice.

• Thoughtful practice consists of a reflective approach that leads to personal learning.

• Successful person-centered practice relies on the integration of several factors:

  • The Nurse's Personal Attributes: Includes open-mindedness, self-awareness, personal responsibility, motivation, leadership skills, and the bravery to question the system.

  • Knowledge Base: The ability to draw upon a comprehensive body of nursing knowledge and evidence-based practice.

  • Clinical Experience: Practical application and learning in real-world settings.

  • Blended Competencies: Cognitive, technical, interpersonal, and ethical/legal skills.

  • QSEN Competencies: Quality and Safety Education for Nurses standards.

• Characteristics of the relationship between caregivers and patients:

  • Continuous, healing relationship.

  • Customized care based on individual needs.

  • Freely sharing of information among all parties.

  • Conducive environment for healing.

  • Safety as a visible priority.

  • Transparency in all care interactions.

  • Inclusion of both the patient and their family in the care process.

The 10 Guiding Principles of Person-Centered Care

1. Caregiver Roles: All team members, regardless of their specific job title, are considered caregivers.

2. Continuous Healing: Care is based on continuous healing relationships rather than isolated encounters.

3. Customization: Care is customized and reflects specific patient needs, values, and personal choices.

4. Knowledge Sharing: Knowledge and information are shared freely between and among patients, care partners, physicians, and other caregivers.

5. Healing Environment: Care is provided in a healing environment designated for comfort, peace, and support.

6. Family Engagement: Families and friends of the patient are considered an essential part of the care team.

7. Priority of Safety: Patient safety is treated as a visible and constant priority.

8. Transparency: Transparency is the rule in the care of the patient, ensuring openness in communication and decision-making.

9. Cooperation: All caregivers cooperate with one another through a common focus on the best interests and personal goals of the patient.

10. Source of Control: The patient is the primary source of control for their own care.

Blended Nurse Competencies

Cognitive Competencies

• Utilizes critical thinking and clinical reasoning.

• Includes the purpose of thinking, adequacy of current knowledge, and identifying potential problems.

• Requires identifying helpful resources and the critique of judgments or decisions.

Technical Competencies

• Developing the specialized manual and technological skills necessary to perform procedures and treatments.

Interpersonal Competencies

• Promoting human dignity and respect for every individual.

• Establishing caring relationships characterized by empathy and professional boundaries.

• Enjoying the rewards of mutual exchange between the nurse and the patient.

Ethical and Legal Competencies

• Understanding legal boundaries and the nursing scope of practice.

• Owning personal strengths and weaknesses to maintain professional accountability.

Clinical Reasoning, Judgment, and Decision Making

• Care can become ritualistic and depersonalized when nurses fail to utilize clinical reasoning and judgment.

• Clinical Reasoning: The process used to think about patient problems in the clinical setting. It involves analyzing a situation, making a judgment, deciding on alternative reasons for findings, and choosing an action.

• Clinical Judgment: The result or outcome of critical thinking, clinical reasoning, and decision-making.

• Characteristics of Decision-Making:

  • Purposeful, informed, and outcome-focused.

  • Guided by standards, institutional policies, ethics codes, and laws.

  • Driven by the needs of the patient, family, and community.

  • Based on principles of the nursing process, problem-solving, and the scientific method.

  • Focuses on safety, quality, reevaluating, and constant self-correcting.

  • Includes patients and stakeholders early in the process.

  • Uses logic, intuition, and creativity.

Problem Solving Approaches

• Trial-and-error: Testing various solutions until one is found that works.

• Scientific: A systematic, seven-step process.

• Intuitive: A direct understanding of a situation based on a background of experience, knowledge, and skill that enables expert decision-making.

• Creative thinking: Developing unique solutions for complex problems.

Tanner Model of Clinical Judgment

1. Noticing: A perceptual grasp of the situation at hand.

2. Interpreting: Developing a sufficient understanding of the situation to respond appropriately.

3. Responding: Deciding on a specific course of action deemed appropriate for the situation.

4. Reflecting: Attending to the patients’ responses to nursing actions while in the process of acting.

The Nursing Process

• Assessing: Systematically collecting patient data.

• Diagnosing: Identifying patient strengths and actual or potential health problems and needs.

• Planning: Developing an individualized plan of care that specifies desired patient goals, expected outcomes, and the nursing interventions most likely to assist the patient in meeting those outcomes.

• Implementing: Executing the established plan of care.

• Evaluating: Measuring the effectiveness of the plan of care in terms of patient goal achievement.

Benefits of the Nursing Process

• For the Patient: Provides scientifically based, holistic, and individualized care; ensures continuity of care; offers a clear, efficient, and cost-effective plan of action.

• For the Nurse: Offers opportunities to work collaboratively with other healthcare professionals; provides the satisfaction of making a difference; allows for professional growth.

Chapter 15: Patient Assessment

• Assessment is the systematic and continuous collection, analysis, validation, and communication of patient data.

• Data reflect how health functioning is enhanced by health promotion or compromised by illness/injury.

• The database includes all pertinent information collected by the nurse and other professionals to enable a partnership with patients.

• Nursing assessments do not duplicate medical assessments.

Types of Nursing Assessments

1. Initial: Conducted shortly after admission to establish a baseline.

2. Focused: Data collection about a specific problem already identified.

3. Quick Priority: Short, focused assessments to determine immediate priorities.

4. Emergency: Performed during a physiological or psychological crisis.

5. Time-lapsed: Scheduled to compare a patient's current status to baseline data obtained earlier.

6. Triage: Used to prioritize patients based on the urgency of their needs.

Data Validation Examples

• Situation A (Abuse): Patient is quiet when the husband is present and recoils from his touch. Subjective data and objective cues (recoiling) match literature for abuse. Validation involves a clarifying statement: "I can't help but notice how quiet you are whenever your husband is here… It seems like you are afraid of him."

• Situation B (Inaccurate BP): Baseline BP is $120/80$. A new reading is $140/90$. The nurse makes an inference of hypertension. Validation involves checking equipment and technique. Common causes for falsely high BP include:

  • Using a manometer not calibrated at the zero mark.

  • Assessing BP immediately after exercise.

  • Viewing the meniscus from below eye level.

  • Applying a cuff that is too narrow.

  • Releasing the valve too slowly.

  • Reinflating the bladder during auscultation.

• In Situation B, the inference is rejected if a second expert nurse gets a reading of $128/80$ and the original nurse recalls reinflating the bladder several times.

Documentation and Privacy

• Immediate Reporting: Verbal report required for critical changes in health status.

• Recording: Initial databases should be entered into the computer or recorded in ink on the day of admission.

• Grammar/Terms: Use good grammar, standard abbreviations, and the patient's own words. Avoid nonspecific terms.

• HIPAA: Nurses must follow the Health Insurance Portability and Accountability Act and institutional policies to safeguard patient privacy.

• Social Media: Follow guidelines provided by the American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN).

Chapter 16: Nursing Diagnosis

• Nursing diagnosis involves interpreting/analyzing data, identifying strengths and health problems, formulating prioritized lists, and referring signs beyond the nurse's scope.

• Diagnostic Reasoning: Nurses must recognize biases and maintain an open mind. Key questions include: Are data accurate/reliable? Does objective data support subjective? Did the client validate the problem? Is there evidence for each statement?

• Types of Diagnoses:

  • Problem-focused (Actual).

  • Risk for (Potential).

  • Health promotion.

• NANDA International: Provides a common terminology for nursing diagnoses to promote communication, research, and cost-benefit analysis.

Comparison Table: Nursing vs. Medical Diagnosis

• Nursing Diagnosis: Focuses on monitoring human responses to actual and potential health problems. Example: Stress Incontinence related to degenerative changes in pelvic muscles.

• Medical Diagnosis: Focuses on correcting or preventing pathology of specific organs or body systems. Example: Cystitis.

Writing Diagnostic Statements

• Problem statement should indicate what is unhealthy or what the patient wants to change.

• The patient problem must precede the etiology (cause).

• Use the phrase "related to" ($r/t$) for etiology and "as evidenced by" ($aeb$) for signs/symptoms.

• Avoid medical diagnoses in the nursing problem statement.

Chapter 17: Outcome Identification and Planning

• Nurses must establish priorities and identify expected patient outcomes using patient/nurse capabilities, time, and resources.

• Levels of Priority:

  1. High priority: Life-threatening problems.

  2. Medium priority: Non-life-threatening.

  3. Low priority: Problems that may not be directly related to the current illness.

Measuring Outcomes

• Components: Subject (the patient), Verb (action), Conditions, Performance Criteria, Target Time.

• Helpful Verbs: List, explain, verbalize, identify, describe, apply, choose, demonstrate.

• Avoid Verbs: Know, understand, learn, become aware (these are not measurable).

• Examples:

  • Pain: "Within $8$ hours, the patient will report pain is absent or diminished."

  • Nutrition: "Within $2$ weeks (by $12/6/25$), the patient will reach a target weight of $122$ lbs."

  • Mobility: "Before discharge, the patient will ambulate the length of the hallway independently."

Chapter 18: Implementation and Nursing's Scope

• Nursing is defined by the ANA as the protection, promotion, and optimization of health and abilities; prevention of illness and injury; facilitation of healing; and advocacy in care.

• Nurse-Initiated Interventions: Monitor health status, reduce risks, resolve problems, promote independence with ADLs, and provide information for informed decisions.

• Standard Implementation Categories:

  • Assess (e.g., assess incisional site frequently).

  • Perform (e.g., hand washing).

  • Culture (e.g., culture site as ordered).

  • Provide (e.g., provide for isolation).

  • Administer (e.g., administer medications as ordered).

  • Insert (e.g., insert intravenous catheter).

Detailed Plan of Care Case Study

Problem #1: Ineffective Cerebral Tissue Perfusion $r/t$ ischemia (thrombosis)

• Short-term Goal: Cerebral perfusion pressure maintained during stay.

• Interventions: Monitor VS every $4$ hours, check pupils ($PEARL$), monitor I&O, monitor pulse oximetry, keep HOB at $30^{\circ}$ or lower, cluster activities.

• Patient Response: BP dropped from $112/60$ at $0800$ to $94/60$ at $1200$. PTT dropped from $68$ to $43$. Progress summary: Worsening symptoms; continue interventions.

Problem #2: Decreased Cardiac Output $r/t$ dysrhythmia

• Short-term Goal: Maintain optimally compensated cardiac output.

• Interventions: Assess pulses, BP every $4$ hours, lung sounds every $2$ hours, urine output, $SaO_2$, and daily weight.

• Patient Response: Lung sounds clear but decreased in bases. Urine output $50\,cc/hr$. Gained $3.5\,kg$ over $3$ days. Progress summary: Maintaining good cardiac output; continue interventions.

Problem #3: Risk for Fluid Volume Excess

• Short-term Goal: Maintain optimal fluid balance evidenced by stable weight and clear lungs.

• Interventions: Daily weight, strict I&O ($1200\,cc/24\,hr$), evaluate urine output, administer Lasix $40\,mg$, monitor electrolytes.

• Patient Response: Intake $480\,cc$, output $250\,cc$ in $5$ hours. Weight gain noted. Electrolytes $\text{WNL}$. Progress summary: Maintaining balance except for weight gain; continue interventions.

Problem #4: Altered Protection $r/t$ anticoagulant therapy

• Short-term Goal: Maintain therapeutic blood levels of anticoagulant.

• Interventions: Monitor for adverse effects (bleeding), monitor VS, ensure IV site integrity, monitor labs (PTT, PT, INR, Hgb, Hct).

• Patient Response: Signs of unexplained bleeding (bruising, petechiae). Hgb $13.2$, Hct $38.9$ (decreasing). Progress summary: Signs of bleeding caused by therapy; continue to monitor H&H downward trend; continue interventions.

Chapter 19: Evaluation

• Evaluation is the process of measuring how well the patient has achieved desired outcomes.

• The Five Elements of Evaluation:

  1. Identifying evaluative criteria and standards.

  2. Collecting data to determine if standards are met.

  3. Interpreting and summarizing findings.

  4. Documenting the judgment.

  5. Terminating, continuing, or modifying the plan.

• Types of Outcomes Evaluated:

  • Cognitive: Patient repeats information or applies knowledge.

  • Psychomotor: Patient demonstrates a new skill.

  • Affective: Change in patient behavior, values, or conversation.

  • Physiologic: Physical assessment findings (e.g., clear lung sounds).

• Evaluative Statements: Must decide if the outcome was met, partially met, or not met, and provide supporting patient data.