Component 2: The Culture of Health Care

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Presentation transcript:

Component 2: The Culture of Health Care Unit 6: Nursing Care Processes Lecture 2 This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015.

The Focus of this Lecture Clinical Judgment Nursing Process Critical Thinking Medication Administration Component 2/Unit 6-2 Health IT Workforce Curriculum Version 2.0/Spring 2011

What is clinical judgment Clinical judgment is an essential path to acquiring the reflective ability and knowledge to understand the condition and needs of the patients. Requires intellectual and professional maturity, the ability to pay attention, to reason and summarize gathered data. (Margot Phaneuf, RN, Dec 17.2008, pg 5) Component 2/Unit 6-2 Health IT Workforce Curriculum Version 2.0/Spring 2011

What Processes Do Nurses Use to Make Clinical Judgments? Critical thinking or clinical reasoning Theoretical and experiential knowledge Nursing process (assessment, diagnosis, planning, interventions, evaluation) Component 2/Unit 6-2 Health IT Workforce Curriculum Version 2.0/Spring 2011

What is Critical Thinking It is a highly individualized complex activity that involves a unique kind of purposeful thinking. One word that explains critical thinking – Reasoning What is critical thinking ? It is a highly individualized complex activity that involves a unique kind of purposeful thinking. One word that explains critical thinking – Reasoning Nurses use Component 2/Unit 6-2 Health IT Workforce Curriculum Version 2.0/Spring 2011

Health IT Workforce Curriculum Version 2.0/Spring 2011 Critical Thinking Critical thinking is a commitment to look for the best way, based on the most current research and practice findings. Solid logical reasons for judgments and actions Component 2/Unit 6-2 Health IT Workforce Curriculum Version 2.0/Spring 2011

Medication Administration Chief responsibility of the nurse Critically thinking though the process will prevent medication errors Checking and rechecking is essential for the safety of the patient Documentation Component 2/Unit 6-2 Health IT Workforce Curriculum Version 2.0/Spring 2011

6 Rights of Administering Medication 1. Right Drug 2. Right Dose 3. Right patient 4. Right route 5. Right time 6. Right documentation Component 2/Unit 6-2 Health IT Workforce Curriculum Version 2.0/Spring 2011

Health IT Workforce Curriculum Version 2.0/Spring 2011 The Nursing Process is an ongoing activity. Nurses are continually assessing the patients health status, response to treatment and medication and evaluating if the plan of care is working and, the care plan is frequently changed to meet the needs of the patients. Component 2/Unit 6-2 Health IT Workforce Curriculum Version 2.0/Spring 2011

Health IT Workforce Curriculum Version 2.0/Spring 2011 Nursing Process An organizational framework for the practice of nursing Systematic system Central to all nursing care Encompasses all steps taken by the nurse in caring for a patient Component 2/Unit 6-2 Health IT Workforce Curriculum Version 2.0/Spring 2011

Benefits of Nursing Process Systematic and orderly method for planning & providing care Enhances nursing efficiency by standardizing nursing practice Facilitates documentation of care Common language for the nursing profession Stresses the independent function of nurses Component 2/Unit 6-2 Health IT Workforce Curriculum Version 2.0/Spring 2011

Five Steps of Nursing Process Assessment – comprehensive data collection of factors related to client health status. Diagnosis – a judgment that identifies actual and potential client health strengths and weaknesses (NANDA Approved Nursing Diagnosis) Component 2/Unit 6-2 Health IT Workforce Curriculum Version 2.0/Spring 2011

Nursing Process (continued) Planning: a two-phase step that determines health related goals and specifies a series of actions to be taken to attain them Implementation: execution of the action plan developed during planning. Evaluation: determining the effectiveness of the implemented action plan either to make needed revisions or restart nursing process. Component 2/Unit 6-2 Health IT Workforce Curriculum Version 2.0/Spring 2011

Benefits of Using the Nursing Process Provides ongoing continuity of care Prevention of duplication Individualized care Standards of care Encourages client participation Collaboration of care with healthcare team members. Component 2/Unit 6-2 Health IT Workforce Curriculum Version 2.0/Spring 2011

Health IT Workforce Curriculum Version 2.0/Spring 2011 Component 2/Unit 6-2 Health IT Workforce Curriculum Version 2.0/Spring 2011

Health IT Workforce Curriculum Version 2.0/Spring 2011 Component 2/Unit 6-2 Health IT Workforce Curriculum Version 2.0/Spring 2011