Nursing Process and Critical Thinking - Comprehensive Notes

Nursing Process and Critical Thinking

Objectives

  • Explain the use of each of the six phases of the nursing process.

  • List the elements of each of the six phases of the nursing process.

  • Describe the establishment of the database.

  • Discuss the components of a patient problem statement.

  • Differentiate between types of health problems.

  • Describe the development of patient-centered goals.

  • Discuss the creation of nursing orders.

  • Explain the evaluation of a nursing care plan.

  • Demonstrate the nursing process by preparing a nursing care plan.

  • Explain North American Nursing Diagnosis Association International (NANDA-I), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC).

  • Describe the use of clinical pathways in managed care.

  • Discuss critical thinking in nursing.

  • Define evidence-based practice.

Introduction to Nursing Process

  • Nursing Defined: Nursing process is a systematic method used by nurses to plan and provide patient care.

  • Nursing Process:

    • It is a problem-solving approach for both actual and potential patient problems.

    • Consists of six phases: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.

Implementation of the Nursing Process by RN and LPN/LVN

  • Assessment:

    • RN (Registered Nurse) is responsible for the initial assessment.

    • LPN/LVN (Licensed Practical/Vocational Nurse) assists with ongoing assessments.

  • Diagnosis:

    • RN identifies the appropriate nursing diagnosis (patient problem).

    • LPN/LVN assists in this process.

  • Outcomes Identification:

    • RN develops individualized goals or expected outcomes linked to nursing diagnoses.

    • LPN/LVN can assist in identifying these outcomes.

  • Planning:

    • RN, with assistance from LPN/LVN, plans interventions to meet patient goals.

  • Implementation:

    • Both RN and LPN/LVN implement the care plan.

  • Evaluation:

    • Both RN and LPN/LVN perform ongoing assessments.

    • RN determines if goals/outcomes have been met.

Assessment Data

  • ANA Definition: Assessment is a systematic, dynamic process to collect and analyze patient data; it's the first step in delivering nursing care.

    • Includes physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors.

  • Purpose: To gather information to identify the patient's health condition.

  • Complete Assessment:

    • Review and physical examination of all body systems.

    • Cognitive, psychosocial, emotional, cultural, and spiritual components.

    • Suitable for patients with stable conditions.

  • Focused Assessment:

    • Used when the patient is critically ill, disoriented, or unable to respond.

    • Used to gather data for specific health problems.

  • LPN/LVN Role: Assist the RN in data collection.

Types of Data

  • Cues and Inferences: Based on data obtained during assessment.

  • Subjective Data:

    • Verbal statements provided by the patient.

  • Objective Data:

    • Observable and measurable signs.

    • Can be recorded.

Sources of Data

  • Primary Source:

    • The patient during assessment.

    • Considered the most accurate source.

  • Secondary Sources:

    • Family members, significant others, medical records, diagnostic procedures, and nursing literature.

    • Used when the patient cannot supply information.

Methods of Data Collection

  • Interview:

    • Biographic data.

    • Reason for seeking health care.

    • History of present illness.

    • Past health history.

    • Environmental history.

    • Psychosocial history.

  • Physical Exams:

    • Head-to-toe format for complete physical examination.

Data Clustering

  • Related cues are grouped together.

  • Focus is directed towards health concerns needing support and assistance.

  • Assists in identifying nursing diagnoses.

Diagnosis

  • Involves identifying the type and cause of a health condition.

  • RN Responsibility: Analyzing and interpreting data to identify health problems that the nurse can treat (nursing diagnosis or patient problem statement).

  • LPN/LVN Collaboration: The RN often collaborates with the LPN/LVN in determining the nursing diagnosis.

Patient Problem Statement

  • A type of health problem identified by the nurse.

    • Based on NANDA International (NANDA-I).

  • Components:

    • Patient's presenting signs and symptoms.

    • Contributing, etiologic (causative), and related factors.

    • Defining characteristics.

    • Patient problems can be actual or potential.

Components of a Patient Problem Statement

  • Patient Problem Statement (Title or label):

    • Can be actual or potential.

    • If potential, include the phrase