NUR 139 MODULE B
Characteristics of a Professional Nurse
- Personal Attributes
- Knowledge Base
- Blended Competencies
- QSEN Competencies
Five Considerations for Developing Methods of Critical Thinking
- Purpose of Thinking
- Adequacy of Knowledge
- Potential Problems
- Helpful Resources
- Critique of Judgment
The Nursing Process
- should be systematic, dynamic, and outcome driven
- Assess the patient to determine the need for nursing care.
- Determine Nursing Diagnoses for actual and potential health problems.
- Identify expected outcomes and Plan care.
- Implement the care.
- Evaluate the results and modify the plan as needed.
- Assessing – performing a nursing assessment
- Diagnosing – making a nursing diagnosis (NANDA)
- Planning – formulating outcome/goal statements and determining nursing interventions
- Implementing Care - taking action
- Evaluating – evaluating progress toward goal (making revisions when needed)
Step One: Assessment
- Assessments may include:
- Differentiate the subjective data from the objective data provided.
- List possible sources of patient data.
- Circle the sources that you think may be available for you to assess in the long term care environment (clinical setting).
- Discuss methods of collecting data.
- Share ideas for collecting data from your assigned resident in the long term care environment (clinical setting).
Step Two: Nursing Diagnosis
- A nursing diagnosis is NOT a medical diagnosis!
- Nursing diagnoses are written to describe problems or issues that nurses can treat independently such as activity, pain, comfort, and tissue integrity or perfusion problems.
- Medical diagnoses identify diseases or sickness, where as nursing diagnoses focus on unhealthy responses to health and illness.
- Problem (from NANDA list) which can be an Actual (present) problem or a Risk (potential) problem
- use the fundamental list of nursing diagnosis provided on Bb for concept mapping
- “Related to” (“R/T”) or "caused by"
- “As evidenced by” (“AEB”)
- Signs & Symptoms (evidence that the problem exists)
- Risk diagnoses only have a problem and an etiology but no S&S
Step Three: Planning
- Establishing priorities - Prioritizing the nursing diagnoses (Maslow)
- Identifying short/long term goals/outcomes
- Developing nursing interventions
Step Four: Implementation
- Describe what occurs during the implementation phase of the nursing process.
- Put the plan into action!
- Document interventions and patient responses
Step Five: Evaluation
- Describe what occurs during the evaluation phase of the nursing process.
- Collect data related to outcomes
- Compare data to desired outcomes
- Draw conclusions about problem status
- Continue, modify, or terminate the nursing care plan
- Give a few examples of factors that may influence the patient’s achievement of outcomes.
- Should be client specific (personalized), realistic, goal oriented, and detail oriented
- A nursing intervention is NOT a physician initiated order
Goal/ Outcome Statement
- The client will … (flip the nursing dx./problem)… As Evidenced By… (list measurable criteria)… include a time frame.