Copyright 2002, Delmar, A division of Thomson Learning

Chapter 1 Critical Thinking and the Nursing Process

Copyright 2002, Delmar, A division of Thomson Learning Course Overview Link to Labs Notes will be provided via web Systems approach Content will become more difficult as we get into systems

Copyright 2002, Delmar, A division of Thomson Learning Class Expectations Come to class Do the readings Don’t be afraid to ask questions If you are confused about something ask for clarification

Copyright 2002, Delmar, A division of Thomson Learning Class Conduct Be on time…or if you are late don’t disrupt the class Be courteous to your classmates Respect other’s opinions and need to ask questions

Copyright 2002, Delmar, A division of Thomson Learning Test Protocols At the start of the scheduled class Will ask you to wait outside until the room is set up Sit where the tests are distributed All bags, books etc. at front or back of room Will ask you to sign in

Copyright 2002, Delmar, A division of Thomson Learning Policy for missed tests You must contact me by noon the day of the test to inform me that you will not be there If able to we will arrange a time to write the test – generally within a week of the scheduled date What happens if you do not contact me?

Copyright 2002, Delmar, A division of Thomson Learning Why do I need to know about assessment? Integral part of what we do as nurses. An assessment of our client should be the first step of any interaction we have Many facets to assessment and this course will help you identify those

Copyright 2002, Delmar, A division of Thomson Learning Nursing Process Assessment Diagnosis Planning Outcome identification Implementation Evaluation

Copyright 2002, Delmar, A division of Thomson Learning Assessment First step in nursing process Purpose  Identifies the patient’s current health status  Actual and potential health problems  Areas for health promotion Sources of information  Health history  Physical assessment  Diagnostic and laboratory data Dynamic phase

Copyright 2002, Delmar, A division of Thomson Learning Health History Gathers subjective data from the patient Information may or may not be validated by physical assessment findings (continues)

Copyright 2002, Delmar, A division of Thomson Learning Health History Possible sources of information  Patient  Family  Neighbors  Friends  Bystanders  Old charts  Medical records

Copyright 2002, Delmar, A division of Thomson Learning Physical Assessment Objective data Observable, measurable data Possible approaches—body systems, head to toe, or functional health patterns

Copyright 2002, Delmar, A division of Thomson Learning Diagnostic and Laboratory Data Objective data May include items such as: blood and urine studies, cultures, X rays, and diagnostic procedures

Copyright 2002, Delmar, A division of Thomson Learning Collaborative Problem Requires the nurse to work jointly with the physician and other members of the health care team in monitoring, planning, and implementing patient care