Introduction to Medical-Surgical Nursing Sasha A. Rarang, MSN, CCN, RN

What is Medical-Surgical Nursing Medical-surgical nursing is the foundation of all nursing practice. Once upon a time and not so very long ago, all nurses practiced the art and science of nursing on wards, everyone was a medical or surgical nurse - that is where all nursing started. Today many nurses choose to work in the specialty of medical-surgical nursing. Medical-surgical nursing has evolved from an entry-level position to an adult health specialty. (Academy of Medical-Surgical Nursing, 2011)

What is Medical-Surgical Nursing Medical-Surgical Nursing - is no longer viewed as stepping-stone but is solid rock and the backbone of every institution. It is the largest group of practicing professionals. Medical-surgical nurses care for adult patients in many settings, such as inpatient care unit, clinics, HMOs, ambulatory care units, home health care, long-term care, skilled nursing homes, urgent care centers, surgical centers, and universities, just to name a few. (Academy of Medical-Surgical Nursing, 2011)

What is Medical-Surgical Nursing Medical-Surgical Nurses A. Have a Vast Set of Skills Are knowledgeable in all aspects of adult health. Have excellent assessment, technical, organizational, and prioritization skills. Teach patients, families, peers, and other health professionals. (Academy of Medical-Surgical Nursing, 2011)

What is Medical-Surgical Nursing B. Are Advocates for Patients Understand the importance of measuring and improving the quality of care delivered Consider patient safety to be the top priority Support patients in their efforts to identify what is in their best interests. (Academy of Medical-Surgical Nursing, 2011)

What is Medical-Surgical Nursing C. Welcome Diversity Care for patients of all ages Manage the care of patients with multiple medical, surgical, and/or psychiatric diagnoses Manage the care of patients with diagnoses across all medical specialties Celebrate that there is always something new to learn Can practice in hospitals, clinics, outpatient surgery centers, MD offices, long-term care facilities, and other practice sites

What is Medical-Surgical Nursing D. Make a Difference in People's Lives Every Day Provide comfort and attention to people who, at that moment, need someone to take an interest in their lives Heal patients physically and emotionally through intuitive experiences that rely on observation and touch. Assist patients in returning to their highest level of functioning Provide dignity and respect in end-of-life decision- making and care

What is Medical-Surgical Nursing E. Are the Backbone of Every Adult-Care Clinical Agency All adult patients are eventually cared for by medical- surgical nurses (Academy of Medical-Surgical Nursing, 2011) Summary of Medical-Surgical Nurse Role Provider of Care 2. Manager of Care 3. Member of the Profession

Activities of the MS Nurse Caregiver Educator Communicator Leader Manager Researcher

Critical Thinking Relationship between Critical Thinking and Nursing Process

What is critical thinking in nursing Critical thinking in nursing is an active, organized, cognitive process use to scrutinized one’s thinking and the thinking of others by application of knowledge and experience, problem solving, and decision making resulting in a nursing. Medical Surgical nurse must be able to correctly identify problems and implement the best solutions (interventions). Critical thinking incorporates reflection, language, and intuition, and it involves through three distinct levels as the nurse gains knowledge and experience while maturing into a competent nursing professional.

What is Critical Thinking Active, organized, cognitive process used to carefully examine one’s thinking and the thinking of others It involves the use of the mind in forming conclusions, making decisions, drawing inferences, and reflecting

Components of Critical Thinking Knowledge Experience Critical Thinking competencies Attitudes Intellect Professional Standards

Critical Thinking and Nursing Judgment How do we make decisions? How do nurses make decisions about patient care? What do we rely on to help us in decision making?

Critical Thinking and Nursing Judgment Not a linear step by step process Process acquired through hard work, commitment, and an active curiosity toward learning Decision making is the skill that separates the professional nurse from technical or ancillary staff

Critical Thinking and Nursing Judgment Good problem solving skills Not always a clear textbook answer Nurse must learn to question, look at alternatives

How do nurse's accomplish Critical Thinking ? Learns to be flexible in clinical decision making Reflect on past experiences and previous knowledge Listen to others point of view Identify the nature of the problem Select the best solution for improving client’s health

Critical Thinking in Nursing Purposeful, outcome-directed Driven by patient, family, and community needs Based on principles of nursing process and the scientific method Requires specific knowledge, skills, and experience New nurses must question

Critical Thinking in Nursing Guided by professional standards and ethic codes Requires strategies that maximize potential and compensate for problems Constantly reevaluating, self-correcting, and striving to improve

Formula for Critical Thinking Start Thinking Why Ask Why Ask the Right Questions Are you an expert?

Aspects of Critical Thinking Reflection Language Intuition

Levels of Critical Thinking Basic Complex Commitment

Critical Thinking Competencies Scientific method Problem Solving Decision Making Diagnostic Reasoning and Inferences Clinical Decision Making Nursing Process

Nursing Process Systematic approach that is used by all nurses to gather data, critically examine and analyze the data, identify client responses, design outcomes, take appropriate action, then evaluate the effectiveness of action Involves the use of critical thinking skills Common language for nurses to “think through” clinical problems

Nursing Process

The Nursing Process Critical Thinking Skills Assessment – Identify human responses to health and illness Observe Diffrentiate between relevant and irrelevant data between important and unimportnat Organize, categorize, and validate data. Diagnosing – Analyze and interpret assessment data Identify clusters and cues Detect Inferences Recognize the problem Defer from making judgments Planning – Determine the best approach to address and resolve the client’s health problem(s) Make generalization Take knowledge and apply to more than one situation Create outcome criteria Theorize Implementation – from conclusions make decisions, and draw inferences about the care plan. Use knowledge base Test theories. Evaluation – interpret evaluative findings to judge both the client’s current health status and whether or not outcome were achieved. Determine accuracy of theories Evaluate based on outcome criteria

Attitude or Mindset that affects how nurse approaches a problem Confidence – feel sure of abilities. Independence – analyze ideas for logical reasoning. Fairness – is objective, non-judgmental. Responsibility – Practices according to standards of practice. Risk Taking – takes calculated chances in finding better solutions to problems. Discipline- develops a systematic approach to thinking. Perseverance , Creativity, Curiosity, Integrity & Humility.

Thinking and Learning Lifelong process Flexible, open process Learn to think and to ANTICIPATE What, why, how questions Look beyond the obvious Reflect on past experience New knowledge challenges the traditional way

Components Of Critical Thinking Standards Ethical criteria for Nursing judgment- Code of Ethics Criteria for evaluation- Standards of care Standards of professional responsibility that nurses strive to achieve are cited in Nurse Practice Acts, JCAHO guidelines, institutional policy and procedure, ANA Standards of Professional Practice Nursing judgment based on ethical criteria. Evaluation that relies on evidence-based-practice Demonstration of professional responsibility.

Critical Thinking Synthesis Reasoning process by which individuals reflect on and analyze their own thoughts, actions, & decisions and those of others Not a step by step process

Critical Thinking Case Study Mrs. Lutz is a 78 yearr old woman who has undergone radiation therapy and three surgeries for cancer. She is not responding well, cannot eat, and is losing weight. The physician has decided to place a subclavian catheter to administer total parenteral nutrition. The nurse takes the informed consent form to the patient to sign and explains to her that “the doctor will place a small tube in your vein to give you more nutrients to help you regain your strength and heal”. Mrs. Lutz says, “I’m so tired of all this pain. I’m not sure I want anything else done, and I surely don’t want to be hurt again.

Case Study Questions What factors does the nurse need to assess that might affect Mrs. Lutz’s ability to consent? Before she signs the consent form, how can the nurse be certain that her consent was truly “informed”?

Case Study Continued The nurse replies to Mrs. Lutz: “Now, now, your doctor has ordered this to make you well. Don’t worry, we’ll make sure you don’t feel a thing. Your doctor will be here soon and he will expect this consent to be signed. Won’t you please sign it now?”

Case Study Questions Evaluate the nurse’s approach to Mrs. Lutz in regard to the invasive procedure. What do you think about it and why?

Nursing Process Traditional critical thinking competency 5 Step circular, ongoing process Continuous until clients health is improved, restored or maintained Must involve assessment and changes in condition

When using the Nursing Process Identify health care needs Determine Priorities Establish goals & expected outcomes Provide appropriate interventions Evaluate effectiveness

Assessment Systemically collects, verifies, analyzes and communicates data Two step process- Collection and Verification of data & Analysis of data Establishes a data base about client needs, health problems, responses, related experiences, health practices, values. lifestyle, & expectations

Assessment Data Subjective Data Objective Data Sources of Data Methods of Data Collection-Interview Interview initiates nurse-client relationship Use open-ended questions Nursing health history

Nursing Diagnosis Statement that describes the client’s actual or potential response to a health problem Focuses on client-centered problems First introduced in the 1950’s NANDA established in 1982 Step of the nursing process that allows nurse to individualize care

Planning for Nursing Care Client-centered goals and expected outcomes are established Priorities are set relating to unmet needs Maslow’s Hierarchy of Needs is a useful method for setting priorities Priorities are classifies as high, intermediate, or low Planning for Nursing Care

Purpose of Goals and Outcomes Provides direction for individualized nursing interventions Sets standards of determining the effectiveness of interventions Indicates anticipated client behavior or response to nursing care End point of nursing care

Goals of Care Goal: Guideposts to the selection of nursing interventions and criteria in the evaluation of interventions What you want to achieve with your patient and in what time frame Short term vs. Long term Outcome Of Care: What was actually achieved, was goal met or not met

Nursing Interventions Interventions are selected after goals and outcomes are determined Actions designed to assist client in moving from the present level of health to that which is described in the goal and measured with outcome criteria Utilizes critical thinking by applying attitudes and standards and synthesizing data

Types of Interventions Nurse-Initiated Physician-Initiated Collaborative Interventions

Selection Of Intervention Using clinical decision making skills, the nurse deliberates 6 factors: Diagnosis, expected outcomes, research base, feasibility, acceptability to client, competency of nurse

Nursing Care Plans Written guidelines for client care Organized so nurse can quickly identify nursing actions to be delivered Coordinates resources for care Enhances the continuity of care Organizes information for change of shift report

Implementation of Nursing Interventions Describes a category of nursing behaviors in which the actions necessary for achieving the goals and outcomes are initiated and completed Action taken by nurse

Types of Nursing Interventions Standing Orders: Document containing orders for the use of routine therapies, monitoring guidelines, and/or diagnostic procedure for specific condition Protocols: Written plan specifying the procedures to be followed during care of a client with a select clinical condition or situation (Pneumonia, MI, CVA)

Implementation Process involves: Reassessing the client Reviewing and revising the existing care plan Organizing resources and care delivery (equipment, personnel, environment)

Evaluation Step of the nursing process that measures the client’s response to nursing actions and the client’s progress toward achieving goals Data collected on an on-going basis Supports the basis of the usefulness and effectiveness of nursing practice Involves measurement of Quality of Care

Evaluation of Goal Achievement Measures and Sources: Assessment skills and techniques As goals are evaluated, adjustments of the care plan are made If the goal was met, that part of the care plan is discontinued Redefines priorities

Evidence-Based Practice in Medical-Surgical Nursing.

Implementing Evidence-Based Practice in Nursing Evidence-Based Practice (EBP) – deliberate se of current best evidence to make decisions about patient care. Considers preferences and values as well as one’s own clinical expertise. Evidence-based practice (EBP) in nursing is using and carrying out nursing practices based on the best available knowledge.

Evidence-Based Practice Evidence-based practice is a way for nurses to examine nursing practices, analyze alternative and contradictory data, and make sound nursing care decisions supported by the best available research evidence. This systematic approach to nursing practice enhances the likelihood that patients will receive the best nursing care possible Critical Thinking is an essential tool for EBP Process to provide quality, cost-effective, safe-patient care. The best source of scientific evidence is research.

Evidence-Based Practice Nursing Steps in conducting EBP. First, information will be presented about asking the clinical question in a way that will give the most relevant evidence. Next, you will be guided through finding the most relevant evidence from the latest clinical practice guidelines or systematic reviews. After gathering the evidence you will learn how to evaluate the validity, relevance, and applicability to the clinical situation. Then you will use and apply critical thinking and appraisal skills to make a clinical decision that is based on integration of the gathered evidence with what you, the nurse, know about the situation at hand. This decision will also incorporate an understanding of available resources and the patient’s preferences and values.

Care and Comfort

Caring in Nursing Practice Caring is central to nursing practice. Caring is a universal phenomenon influencing the ways in which people think, feel, and behave in relation to one another. Caring determine what matters to a person, it describes a wide range of involvement. Clients perception of caring : Caring emphasizes what clients expects from their caregivers.

Client’s Perception of Caring Client’s value the nurses effectiveness in performing tasks and affective dimension of nursing care. What client’s perception is important because health care is lacing greater emphasis on client satisfaction. Caring is a moral imperative.

Caring in Nursing Practice Caring is a product of of person’s culture, values, experiences, and relationships with others. Nursing behaviors related to caring inlcude: Providing presence – being there and being with. Touch – comforting approach. Task-oriented touch caring touch protective touch. Listening Knowing the client Spiritual Caring

Leadership in the Medical- Surgical Setting

The leadership role of medical-surgical nurses: what is it? Health care providers are called to promote health care that is safe, effective, client-centered, timely, efficient, and equitable (Institute of Medicine, 2001). At the same time, evidence-based practice initiatives, new quality improvement approaches, and informatics and technology advances are imposed on nurses in the workplace (Institute of Medicine, 2003). These challenges present some pretty tall mountains for nurses to climb. However, strongly medical-surgical nurses can address these challenges in the microsystem by assuming a leadership role in the workplace.

Leadership Role for Medical-Surgical Nurse Leadership role emerge from the nurse's professional commitment to quality patient care and a work environment that fosters excellence in practice. Medical-surgical nurses and their employers would recognize the nurses' knowledge as expert caregivers, and these medical- surgical nurse's would be willing to act to change nursing care and/or the environment to improve patient outcomes. Some examples: A medical-surgical nurse would volunteer to facilitate the implementation of an evidence-based practice project that examines the evidence for decubitus ulcer management. Another medical-surgical nurse would take the lead on a project to assess the root of medication errors on the unit. patient care and their responsibility as professional nurses.

Leadership in MS Nursing A nurse with an interest in informatics would be the unit "cheerleader" and facilitator in implementing new software technology on the unit. These medical-surgical nurse leaders would also be aware of issues that arise related to patient care and would initiate changes in care to address those issues. Medical-surgical nurses would recognize the need for change and lead specific initiatives to integrate change into the workplace. These nurses would be willing to tackle a project because of their commitment to quality

Leadership In MS Nursing The scope of medical-surgical nurse leadership role is local, at the unit level, and more focused. This role is founded on the expert knowledge that medical-surgical nurses have. It is grounded in professional responsibility, and it is supported by skills in group facilitation and critical thinking. Assuming a leadership role on the unit may seem like an overwhelming task. However, medical-surgical nurses have the basic skills to move into roles that facilitate change and improve patient care.