CRITICAL THINKING &NURSING PROCESS THE CORNERSTONE OF NURSING PRACTICECRITICAL THINKING:People use critical thinking wherever they want to use clear, focused thinking to achieve a result.Nurse need to be critical thinkers when working with the patients to help them cope with the disease or illness,

DEFINITION:Critical thinking is defined as: a systematic way to form and shape ones thinking. It functions purposefully and exactingly. It is thought that is disciplined, comprehensive based on intellectual standards and a result well reasoned.

PURPOSE:It is guided by standards, policies and procedures, ethics, codes and laws.Based on principles of nursing process, problem solving and the scientific method.Carefully identifies the key problem, issues and risks involved in the care of patient, families.Is driven by patient, family and community needs as well as nurses needs to give competent, efficient careCalls for strategies that makes the most of the human potential and compensate for problems caused by human nature.Is constantly revaluating, self- correcting, striving to improve.

INDICATORS:It is the evidence based descriptions of behaviours that demonstrates the knowledge, characteristics and skills that promote critical thinking in clinical practice.Developing the method of critical thinking:Purpose of ThinkingAdequacy of KnowledgePotential ProblemsHelpful ResourcesCritiques of Judgement/ DecisionDeveloping the attitude & depositions to think critically:

NURSING PROCESS & NURSING CARE PLAN

DOWN HISTORY LANEThe term nursing process and the framework it implies are relatively new. In 1955, Hall originated the term (care, cure, core), 3 steps: note observation, ministration, validationJohnson (1959), Nursing seen as fostering the behavioral functioning of the client.Orlando (1961), identified 3 steps: clients behavior, nurses reaction, nurses action. Nursing process set into motion by clients behaviorWeidenbach (1963) were among the first to use it to refer to a series of phases describing the process.Wiche (1967) Nursing is define as an interactive process between client and nurse. 4 steps: Perception, Communication, Interpretation, Evaluation. Yura and Walsh (1967) suggested the 4 components APIE.Knowles (1967) described nursing process as: discover, delve, decide, do, discriminate.

AMERICAN NURSES ASSOCIATIONPublished standards of nursing practice. Diagnosis distinguished as separate step of nursing process (1973)

Published Nursing a Social Policy Statement. Diagnosis of actual and potential health problems delineated as integral part of nursing practice (1980)

Published Standard of Clinical Nursing Practice. Outcome identification differentiated as a distinct step of the nursing process. Therefore, the six steps of the nursing process are as follows: A.D.OI.P.I.E. (1991).

What is a Process?It is a series of planned actions or operations directed towards a particular result or goal.

NURSING PROCESS:It is a systematic, rational method of planning and providing individualized nursing care.

THE NURSING PROCESS:Is the underlying scheme that provides order and direction to nursing care. It is the essence of professional nursing practice.It has been conceptualized as a systematic series of independent nursing actions directed toward promoting an optimum level of wellness for the client.It is cyclical; the components follow a logical sequence, but more than one component may be involved at any one time.

PURPOSE OF NURSING PROCESS:To identify a clients health status, actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs.

It helps nurses in arriving at decisions and in predicting and evaluating consequences.

It was developed as a specific method for applying a scientific approach or a problem solving approach to nursing practice.

CHARACTERISTICS OF NURSING PROCESS:Problem-OrientedGoal OrientedUniversally ApplicableOpen & FlexibleCyclic & dynamicClient Oriented & Individualized ApproachInterpersonal CollaborationSystematic, PlannedInvolves CreativityEmphasis on FeedbackIMPORTANCE OF NURSING Process:Ensures quality careSystematic & scientific plan of careCare provided is available in written form.Avoids duplication & omissions.Enhances communications as well as cooperationHelps in meeting the patients individualized preferences & needs.Participation of patient in care is encouragedUsed as a legal document.Used as a learning tool for medical and nursing studentsProvides an organized method of giving careHelps nurses to gain satisfaction by getting results.Promotes flexibility.Helps improve continuity of care.Nursing ProcessOrganizedSYSTEMATICGoal-OrientedHumanistic CareEfficient EffectivePHASES OF NURSING PROCESS ARE INTERRELATED:NURSING PROCESS:ASSESSMENT & DATA COLLECTION

ASSESSMENT:To establish baseline information on the client.To determine the clients normal function.To determine the clients risk for diagnosis function.To determine presence or absence of diagnosis function.To determine clients strengths.To provide data for the diagnostic phase.

ACTIVITIES OF ASSESSMENT:COLLECT DATA

VALIDATE DATA

ORGANIZE DATA

RECORDING DATA

Assessment involves reorganizing and collecting CUES:Objective (overt) & Subjective (covert).

TYPES OF ASSESSMENT:Initial Assessment-Initial identification of normal function, functional status and collection of data concerning actual and potential dysfunction.Focus Assessment-Status determine of a specific problem identified during previous assessment.Time Lapsed Reassessment-Comparison of client current status to baseline obtained previously, detection of changes in all functioning health problems after an extended period of time .Emergency Assessment- Identification of life threatening situation.

CLINICAL SKILLS USED IN ASSESSMENT:Observation act of noticing client cues.*looking, watching, examining, scrutinizing, surveying, scanning, appraising.*uses of different senses: vision, smell, hearing, touch.Interviewing interaction and communication.Physical ExaminationINSPECTIONPERCUSSIONAUSCULTATIONINTUITION- defined as insights, instincts or clinical experiences to make judgment about client care.

Data collection:TYPES OF DATA:Subjective & Objective DataCHARACTERISTICS OF DATA:PurposefulCompleteFactual & AccurateRelevantSOURCES OF DATA:PatientFamily & Significant OthersPatient RecordsMedical history, Physical Examination & Progress NotesMETHODS OF DATA COLLECTION:Interview & Health HistoryPhysical ExaminationDiagnostic & Laboratory DataINTERPRETATION OF ASSESSMENT DATA & MAKING NURSING JUDGEMENT.DATA VALIDATIONComparison of the collected data with another sourceANALYSIS & INTERPRETATIONDATA CLUSTERINGDATA DOCUMENTATION4 PHASES OF INTERVIEW:Preparatory Phase (Pre-interaction)Introductory Phase (Orientation)Maintenance Phase (Working)Concluding Phase (Termination)

COMMUNICATION:A process in which people affect one another through exchange of information, ideas, and feelings.

Documentation/Recording is a vital aspect of nursing practice.

Include both oral and written exchange of information between caregivers.

MODES OF COMMUNICATIONVerbal Communication - Uses spoken or written words.

Non-verbal Communication - Uses gestures, facial expression, posture/gait, body movements, physical appearance (also body language), eye contact, tone of voice.

CHARACTERISTICS OF COMMUNICATION:SIMPLICITY- commonly understood words, brevity, and completenessCLARITY- exactly what is meantTIMING and RELEVANCE- appropriate time and consideration of clients interest and concernsADAPTABILITY- adjustment depending on moods and behaviorCREDIBILITY- worthiness of belief

DOCUMENTING & REPORTINGDOCUMENTATION- Serves as a permanent record of client information and care.REPORTING- takes place when two or more people share information about client careNURSING DOCUMENTATION: the charting of documents, the professional surveillance of the patient, the nursing action taken in the patients behalf, and the patients programs with regards to illness.

PURPOSES OF CLIENT RECORD/CHART:CommunicationLegal DocumentationResearchStatisticsEducationAudit and Quality AssurancePlanning Client CareReimbursementTYPES OF RECORD:Source Oriented Medical Recordtraditional client recordFIVE BASIC COMPONENTS:Admission sheetPhysicians order sheetMedical historyNurses notesSpecial records and reports

B. Problem-oriented medical record (POMR)- arranged according to the source of information.

FOUR BASIC COMPONENTS:DatabaseProblem listInitial list of orders or care plansProgress notes:Nurses notes (SOAPIE)Flow sheetsDischarge notes or referral summaries

CHARACTERISTICS OF A GOOD RECORDINGBREVITY.USE OF INK / PERMANENCE.ACCURACY.APPROPRIATENESS.COMPLETENESS & CHRONOLOGY / ORGANIZATION / SEQUENCE / TIMING.USE OF STANDARD TERMINOLOGY.SIGNED.In case of ERROR.CONFIDENTIALITY.LEGAL AWARENESS.LEGIBLE.DO NOT use the word PATIENT or PT in the chart.A HORIZONTAL LINE drawn to fill up a partial line.

REPORTINGCHANGE-OF-SHIFT REPORTS OR ENDORSEMENT. -for continuity of care / health care needs.TELEPHONE REPORTS.-provide clear, accurate, & concise information-includes: when, who made/was, whom, what info given/received.TELEPHONE ORDERS.- RNs duty, must be signed w/in 24 hours.TRANSFER REPORTS- from one unit to another.

SOME LEGAL SIGNIFICANCE OF REPORTING:Chart AccuratelyChart ObjectivelyChart PromptlyMake No Mention of an Incident Report in the ChartWrite Legibly and Use Only Standard Abbreviations

THIRTEEN CHARTING RULES:Write Neat and LegiblyUse Proper Spelling and GrammarWrite with Blue or Black Ink and Use Military timeUse Authorized AbbreviationsTranscribe Orders CarefullyDocument Complete Information About MedicationChart Promptly

Never Chart Nursing Care or Observation Ahead of Time.Clearly Identify Care Given by Another Member of the Health Care Team.Dont Leave Any Blank Spaces on Chart Forms.Correctly Identify Late Entries. Correct Mistaken Entries Properly. Dont Sound Tentative Say What You MeanSIX MORE RULES:Dont Tamper with Medical Records.Dont criticize other Health Care Professionals in the chart.Dont Document any Comments that a patient or family member makes about a potential lawsuit against a health care professional or the hospital.Eliminate bias from written descriptions of the patient.Precisely document any information you report to the doctor.Document any potentially contributing patient acts.

NURSING PROCESS: NURSING DIAGNOSIS

NURSING DIAGNOSIS:The word Diagnosis is derived from the words meaning to distinguish or to know.According to North American Nursing Diagnostic Association (NANDA) 1992 defines nursing diagnosis as following: A clinical judgement about individual family or community, responses to actual and potential health or life process. Nursing diagnosis provides the basis for collection of nursing interventions to achieve outcomes for which the nurse is accountableA nursing diagnosis is a clinical judgement about individual, family or community responses to actual and potential health problems for life processPURPOSES OF NURSING DIAGNOSIS:Basis for nursing interventions to achieve outcomes for which the nurse is accountableFocuses on actual or potential response to a health problemLeads to development of an individualized plan of care.Helps to analyze collected data.Helps to identify the clients strengths and weaknessHelps to identify the client normal functional level statement.NANDA DIAGNOSIS:NANDA DIAGNOSIS is a list of diagnostics made by the NORTH AMERICAN NURSES DIAGNOSTIC ASSOCIATION.The diagnosis provides a common language which facilitates communication among nurses.

NANDA diagnosis is used because:Provides a precise definition that gives a member of the health care team a common language for understanding the patients needsDistinguishes the nurses role from that of the physician or other health care professionals.Helps nurses focus on the scope of nursing practice.Types of nursing diagnosis:NANDA , Internationally identifies 4 types of nursing diagnosis:Actual DiagnosisHigh-Risk DiagnosisWellness Nursing DiagnosisSyndrome DiagnosisComponents of a nursing diagnosis:Diagnostic labelRelated factorDefinitionRisk factorSupport of the diagnostic statementTypes of nursing diagnosis:One-Part Statement DiagnosisTwo-Part Statement DiagnosisThree-Part Statement Diagnosis

Sources of diagnostic errors:Errors can occur in the diagnostic data duringData CollectionData InterpretationData ClusteringDiagnostic StatementNursing diagnosis application in care planning:Provides direction for the planning process and selection of the nursing interventionsHelps in communicating the client centered problems to other professionalsEnsures quality nursing careDevelops Specific nursing interventions for each clientCoding of nursing care plans in computer helps for direct access.Helps to assess the nurses role in health careIt helps the clinical, educational, research, legislation and nursing as a profession.Helps to bridge the gap between knowledge & practice.NURSING PROCESS:PLANNING

Planning:It is a purposeful activity which involves critical thinkingIt is the determination of what is to be done, when it is to be done, where it is to be done and who will do and also how to evaluate the results.DEFINITION:According to Kozier: Planning is a deliberate systematic phase of the nursing process that involves decision making and problem solving.According to Kypt: Planning is defined as the selecting and carrying out of series of action assigned to achieve stated goals.Purpose:Direct client care activitiesPromote continuity of careFocus charting requirementsAllow for delegation of specific activitiesTYPES:Initial PlanningOngoing PlanningDischarge PlanningPHASES OF PLAnning:Setting prioritiesHigh PriorityIntermediate PriorityLow PriorityGoals & expected outcomes

Purpose:Evaluates the clients progress towards desired outcomesEvaluates the effectiveness of selected nursing interventions.

TYPES:SHORT TERM GOALSLONG TERM GOALSEXPECTED OUTCOMES:It is specific measureable change in a patients status that the nurse expects to occur in response to the nursing careCharacteristics of outcome criteria:

Characteristics of a well stated gaols/ expected outcomes:Derived primarily from the first clause of the nursing diagnosis.Possible to achieve.Stated in terms of client responses rather than nursing activities.Statement of one specific client behavior.Specific & Concrete.Appraisable & Measurable.Valued by the client & family.Compatible with therapies of other professionals.

nursing interventions

nursing strategies:A Nursing Intervention is any direct care treatment that a nurse performs on behalf of the client, whether nurse initiated or physician initiated.TYPES OF NURSING INTERVENTIONS:Independent interventionsDependent interventionsCollaborative interventionsCriteria for choosing nursing strategy:Safe &appropriate for the individuals age, health.Achievable with the resources availableCongruent with the clients values &beliefsCongruent with other therapiesBased on nursing knowledge and experience or knowledge from relevant sciencesWithin established standards of care as determined by state laws, professional associations and the policies of the institution.Writing nursing orders:Nursing orders are instructive for the specific activities the nurse performs to help the client to meet the established health care goals.A complete well written nursing order is composed of 5 components:Date:Specific action verbContent areaTime elementSignature Developing nursing plans:The nursing care plan is a written guide that organizes information about a clients care into a meaningful whole. It includes the actions nurses must take to address the clients nursing diagnosis and meet the stated goals.

Purposes Of a written care plan:To provide direction for individualized care of the clientTo provide for continuity of careTo provide direction about what needs to be documented on the clients progress notes.To serve as a guide for assigning staff to care for the client.To serve as a guide for reimbursement from ,medical insurance companies often called third party reimbursement.To provide for individual and family participation in the nursing care plan.To outline a program for health education of individuals and significant others.To encourage adequate discharge planning.To provide a source of information for quality improvement and research. Writing a nursing plan of careCriteria The plan must be developed by an registered nurseIt must be documented in the clients health record It must reflect the standards of care established by the institution and the profession.The plan of care is nursing centered.The plan of care is a step by step process.

Standardized nursing care plan:Sufficient data are collected to substantiate nursing diagnosis.At least one goal must be stated for each nursing diagnosisOutcome criteria must be identified for each goalNursing interventions must be specifically developed to meet the identified goalEach intervention should be supported by a scientific rationale.Evaluation must address whether each goal was completely met, partially met or not met.Guidelines for writing a nursing plan:Date & sign the planUse the category headingsNursing DiagnosisGoals/Outcome CriteriaNursing ordersEvaluation and include a date for the evaluation of each goal.Use standardized medial or English symbols and key words rather than complete sentences to communicate your ideas.Refer to procedure books or other sources of information rather than including all the steps on a written plan.Tailor the plan to the unique characteristics of the client by ensuring that the clients choices are included. This reinforces the clients individuality and sense of control.ContdEnsuring that the nursing plan incorporates preventive and health maintenance aspects as well as restorative.Ensure that the plan contains orders for ongoing assessment of the client.Include collaborative and coordination activities in the plan.Include plans for the clients discharge and home care needs.Types of nursing plan:Student Nursing Care PlansIndividually Developed Nursing Care PlansStandardized Nursing Care PlansTeaching PlansPractice GuidelinesCase Management Care PlansComputerized Plans

Nursing process:implementation

Definition:Implementation refers to the action phase of the nursing process in which nursing care is provided. It is the actual initiation of the plan and recording of nursing actions.Bulechek define nursing interventions as any direct treatment that a nurse performs on behalf of a client. These treatments include nurse- initiated treatments resulting from nursing diagnoses and performance of the daily essential functions for the client who cannot do these.Implementation skills:Intellectual/ Cognitive SkillsInterpersonal/ Affective SkillsTechnical/ Conative SkillsImplementation activities:Types of nursing interventions:Cognitive InterventionsEducational InterventionsSupervisory InterventionsInterpersonal InterventionsCoordinating InterventionsSupportive InterventionsPsychosocial InterventionsTechnical InterventionsMaintenance InterventionsSurveillance InterventionsPsychomotor InterventionsResponsibilities in implementation of nursing care:Review of planned interventions for appropriateness.Scheduling & organizing the interventionsCollaborating with other team membersSupervising & delegating nursing care by other members of the nursing team.Achievement of the organizational & client care goals.Providing direct nursing care.Providing counsellingInvolving the client in health careTeaching the client & familyMaking referrals to other health care professionals.Documenting nursing care provided.

Nursing process:evaluation

DEFINITION:To evaluate is TO JUDGE or TO APPRAISE.Evaluation is a planned, ongoing, purposeful activity in which client and health care professionals determine: The clients progress towards goals achievementThe effectiveness of nursing care plan.

Evaluation is defined as the judgement of the effectiveness of nursing care to meet client goals based on the clients behavioural responses.Purposes of evaluation:To collect the objective & subjective data to make judgements about nursing care developed.To examine the clients behavioural responses to nursing interventions.To compare the clients behavioural responses with predetermined outcome criteriaTo appraise the extent to which client goals were attained or problems resolved.To appraise involvement and collaboration of the client, family members, nurses and health care team members in health care decisionsTo provide a basis for the revision of the nursing plan of the care evaluationTo monitor the quality of nursing care and its effect on the clients health status.Types of evaluation:Structure EvaluationProcess EvaluationOutcome EvaluationOngoing EvaluationIntermittent EvaluationTerminal Evaluation

Relationship of evaluation to other nursing process phases:

Steps in evaluation:Review client goals and Outcome CriteriaCollect DataMeasure Goal/ Outcome CriteriaAssess the facilitators of Goal AttainmentAssess the barriers to Goal AttainmentRecord Judgement or Measurement of Goal Attainment.Revise or Modify the Nursing Care Plan.Conclusion:The nursing process is the best way to provide best nursing care to the patients. Adoption of nursing process enable nurses to provide systematically planned nursing care and interventions and the nursing process also safeguards the nurse and her patients life from medical legalities.