Foundations of Nursing, Critical Thinking, QSEN & Clinical Judgment

Foundations of Nursing: Definition & Scope

  • ANA (paraphrased) definition: Nursing combines art and science of caring and centers on protection, promotion & optimization of health, prevention of illness/injury, facilitation of healing, alleviation of suffering, advocacy for individuals/families/groups/communities/populations.
  • Key words highlighted in class:
    • Art (compassion, presence, interpersonal skills)
    • Science (empirical data, physiology, technology)
    • Advocacy (speak for vulnerable clients: sedated trauma pt, NICU infant, LTC elder without family)
    • Care extends beyond individuals → families, groups, entire communities.
  • Text reference: Table 1-2 (page 13) – roles & functions overview.

Traditional & Emerging Nursing Roles

  • Caregiver – address physical, emotional, spiritual needs directly at bedside.
  • Communicator – apply therapeutic communication: open-ended questions, reflection, clarification; avoid slang (“Hey girl…”).
  • Teacher / Educator
    • Develop individualized teaching plans.
    • Target literacy ≈ 4ᵗʰ – 6ᵗʰ grade in Arkansas.
    • Translate jargon (e.g., “bounding popliteal pulse”) into client-friendly terms.
  • Counselor – informal problem-solving & referral (e.g., discuss diet/exercise when BP meds unaffordable; connect to Medicaid).
  • Leader / Change Agent – spearhead QI projects (ex: catheter-associated UTI reduction).
  • Researcher – collect/analyze data; implement EBP; BSN opens wider research opportunities.
  • Advocate – protect legal & human rights.
  • Collaborator – integrate work with: RT, PT/OT, social work, techs/CNAs, MD/DO, APRN, PA, LPN, etc.

Aims of Nursing

  • Health Promotion
    • Enhance well-being; address diet, exercise, sleep hygiene, hydration.
    • Consider socioeconomic status, culture, spirituality when teaching (e.g., affordability of fresh produce, pork restrictions).
  • Illness Prevention
    • Educate, assess readiness to change (e.g., long-term smoker not ready for cessation).
    • Use community resources, screenings, immunizations.
    • Healthy People 2030 goals guide priorities.
  • Health Restoration
    • Early detection, rehabilitation (e.g., diabetic education, post-op joint rehab).
    • Focus on returning to baseline or optimal functioning.
  • Facilitation of Coping with Disability or Death
    • Hospice & palliative care; support families.

Critical Thinking in Nursing

  • Purpose: Decide how to intervene for a specific patient with the most accurate knowledge.
  • Must evaluate:
    • Adequacy & bias of data.
    • Potential problems (e.g., neuropathy in diabetes).
    • Helpful resources (peers, literature, policies).
    • Options, consequences, error avoidance.
  • Desirable thinker traits: curious, inquisitive, logical yet intuitive, flexible, open-minded, diverse-sensitive.

QSEN (Quality & Safety Education for Nurses) Competencies

Table reference: p. 359; Clinical rubric aligns with these six domains.

  1. Patient-Centered Care – respect values, involve family, tailor teaching.
  2. Teamwork & Collaboration – communicate effectively with entire inter-professional team.
  3. Evidence-Based Practice (EBP) – integrate best current evidence (e.g., x-ray confirmation for NG placement instead of auscultation).
  4. Quality Improvement (QI) – use data to improve systems (e.g., track Foley-insertion technique → ↓ CAUTIs).
  5. Safety – minimize risk (falls, med errors, readmissions); NCLEX core.
  6. Informatics – use EHR, eMAR, decision-support, data sharing.
Clinical Evaluation Rubric Highlights
  • Students graded on each QSEN domain.
  • Safety infractions, lack of patient-centered inquiries, or inability to use EHR reduce scores.
  • Quality-improvement understanding assessed via written questions/projects throughout semester.

Nursing Process ADPIE=Assess,Diagnose,Plan,Implement,EvaluateADPIE = {\text{Assess},\text{Diagnose},\text{Plan},\text{Implement},\text{Evaluate}}

  • Assess (A) – gather subjective & objective data every encounter (patient, environment, family dynamics).
  • Diagnose (D) – formulate nursing diagnoses (e.g., Impaired Gas Exchange, Acute Pain) supported by data; not medical dx.
  • Plan (P) – set goals & select interventions (sit up, O2O_2, incentive spirometer).
  • Implement (I) – execute & document; if undocumented → “didn’t happen.”
  • Evaluate (E) – compare outcomes; if unmet, reassess & revise plan; loop is continuous.

Tanner’s Clinical Judgment Model (CJM)

  1. Noticing – focused & holistic assessment; recognise deviations from baseline.
  2. Interpreting – analyze meaning of data; link pathophysiology.
  3. Responding – implement actions, delegate, communicate.
  4. Reflecting – evaluate in action (real-time) & on action (after); learn & adjust.

NCSBN Clinical Judgment Measurement Model (CJMM)

Outer ring = ADPIEADPIE
Inner six layers (cyclical):

  1. Recognize Cues – gather/cluster relevant findings.
  2. Analyze Cues – interpret significance; compare to norms.
  3. Prioritize Hypotheses – rank possible problems.
  4. Generate Solutions – plan interventions, anticipate orders.
  5. Take Action – implement & document.
  6. Evaluate Outcomes – reassess; revise as needed.
Mapping Models
  • Recognize Cues ⇄ Assess
  • Analyze/Prioritize ⇄ Diagnose
  • Generate Solutions ⇄ Plan
  • Take Action ⇄ Implement
  • Evaluate Outcomes ⇄ Evaluate

Case Study Walk-Through (Ms Periwinkle)

46 y female, right-lower-quadrant (RLQ) pain. Current orders include IV NS, CT, XR, labs.

Vital Signs BP=150/85 mmHg; HR=125 bpm; RR=19 /min; T=102.5∘!F; SpO2=97%BP=150/85\ \text{mmHg};\ HR=125\ \text{bpm};\ RR=19\ /min;\ T=102.5^\circ!F;\ SpO_2=97\%

Step 1 – Recognize Cues
  • Pertinent: RLQ stabbing pain 10/10; fever >100.4^\circF; tachycardia; mild HTN; recent morphine with minimal relief.
  • Cluster suggests acute inflammatory process.
Step 2 – Analyze / Prioritize Hypotheses
  • Possible diagnoses:
    • Appendicitis (most likely)
    • Bowel obstruction
    • Ectopic pregnancy (rule-out)
  • Urgent concerns: control infection & prevent sepsis; manage uncontrolled pain.
Step 3 – Generate Solutions
  • Antipyretic (acetaminophen), broad-spectrum IV antibiotic, NPO status, IV fluids (100 mL·h^{-1}), pain re-assessment, surgical consent prep, abdominal assessment, lab & imaging follow-up.
  • Indicated vs Contraindicated examples:
    • O<em>2<em>2 therapy – non-essential (SpO</em>2</em>2 adequate).
    • Oral food – contraindicated (NPO pre-op).
    • Antibiotics – indicated.
Step 4 – Take Action
  • Start ordered antibiotics, titrate fluids, repeat VS q15 min, communicate findings to Dr Jones, coordinate STAT CT if deterioration.
Step 5 – Evaluate Outcomes
  • Reassess pain within 30 min30\text{ min} (IV) / 60 min60\text{ min} (PO).
  • Desired: ↓ pain score, ↓ temp, stabilized VS.
  • If worsening (higher fever, ↑ pain): escalate → rapid surgery, change antibiotics, sepsis bundle.

Practical Tips & Ethical Emphasis

  • Patients are people, not room numbers or checklist items; nursing is a privilege.
  • Remain flexible (halt assessment to assist code), open-minded (diversity, spirituality), model healthy behaviors (avoid public smoke breaks).
  • Pain rarely life-threatening → treat root cause first.
  • Documentation = Legal Proof – absence of charting can lose court cases.

Numerical & Reference Recap

  • Arkansas average literacy: 4th–6th4^{th} – 6^{th} grade.
  • Vital sign criteria (example): Fever >100.4^\circ F; tachycardia >100\ bpm; hypertension >140/90\ mmHg.
  • Nursing process mnemonic: ADPIEADPIE.
  • CJMM = 6 internal steps aligning with ADPIEADPIE.
  • Key textbook tables:
    • Foundations roles Table 1-2 p. 13
    • QSEN summary p. 359
    • Table 13-3 – detailed QSEN vs Nursing Process mapping.

End of study notes – covers all lecture objectives, examples, models, ethical considerations, and case-application.