1. The Nursing Process and Critical Thinking
Chapter 12
The Nursing Process and Critical Thinking

2. Learning Objectives Describe the components of the nursing process.
Explain the role of the LPN/LVN in the nursing process.
Describe the proper documentation of the nursing process.
Describe the relationship between the nursing process and the process of documentation.
Explain the relationship between the nursing process and critical thinking.
Describe the characteristics of a critical thinker.
Describe how critical thinking skills are used in clinical practice.
Describe principles of setting priorities for nursing care.

3. Assessment
Involves collecting data about the health status of the patient
A registered nurse must perform the initial admission assessment for each patient
The LVN/LPN collects data through surveillance and monitoring and performs focused nursing assessments
A focused nursing assessment is defined as “an appraisal of the client’s status and situation at hand that contributes to ongoing data collection.”
What does the word data mean?

4. Assessment Subjective data Objective data
Information reported by patient and family in a health history in response to direct questioning or in spontaneous statements
Objective data
Information that nurse or other members of health care team obtain through observation, physical examination, or diagnostic testing
Subjective data usually are documented in the patient’s own words and include information such as previous experiences and sensations or emotions that only the patient can describe.
Objective data can be seen or measured (e.g., heart rate, wound condition, and laboratory values).
What are sources of subjective data and objective data?

5. Physical Examination Inspection
Purposeful observation of the person as a whole and then systematically from head to toe
When does inspection of the patient begin?

6. Figure 12-1

7. Physical Examination Palpation
Uses touch to assess various parts of the body and helps to confirm findings that are noted on inspection
The hands, especially the fingertips, are used to assess skin texture, moisture, and temperature or the presence of swelling, lumps, masses, tenderness, or pain.
What is one thing you should do before palpating the patient?
When examining the abdomen, palpation should be light at first for surface characteristics and then deeper for abdominal contents.

8. Figure 12-2

9. Physical Examination Percussion
Tapping on the skin to assess the underlying tissues
What are the most common areas for percussion?
Short, sharp strokes elicit sounds and subtle vibrations that are characteristic of underlying organs and certain conditions.
To percuss:
Place one hand flat on the skin over the area to be assessed.
Use the tip of the middle finger of your other hand to lightly tap the middle finger of the hand that rests on the patient.
Tap two times just behind the nail bed before moving to the next area.

10. Figure 12-3

11. Figure 12-4

12. Physical Examination Auscultation
Listening to sounds produced by the body
Auscultation is performed with a stethoscope.
What is the difference between the diaphragm and the bell of a stethoscope?

13. Figure 12-5

14. Nursing Diagnosis Derived from data gathered during the assessment
Nursing diagnosis different from medical diagnosis
Focuses on the patient’s physical, psychological, and social responses to a health problem or potential health problem
The RN formulates nursing diagnoses; the LVN/LPN is expected to assist with identifying patient needs and implementing plan of care
Nursing diagnoses provide a basis for planning nursing interventions that can help prevent, minimize, or alleviate the problem.
What is a medical diagnosis?

15. Nursing Diagnosis
North American Nursing Diagnosis Association (NANDA International)
Develops and revises nursing diagnoses
Table 12-1: list of accepted nursing diagnoses
Written in a PES format
P = problem
E = etiology or cause of the problem
S = signs and symptoms of the problem
The PES format helps make the general nursing diagnosis fit a specific patient care problem.
What is an example of a nursing diagnosis?

16. Planning
Develop a nursing care plan for the patient based on nursing diagnoses
Nursing care plans a form of communication with other health care professionals to ensure continuity of care, prevent complications, and provide for health teaching and discharge planning
Who is responsible for initiating the plan of care?

17. Planning Steps in planning nursing care
Determine priorities from the list of nursing diagnoses
Set long-term and short-term goals to determine outcomes of care
Develop objectives to reach the goals
Write nursing orders to direct care to meet the goals
Priorities established according to the most immediate needs of the patient
What are the steps in planning nursing care usually based on?
Goals should be stated in terms of patient outcomes.
Nursing orders are the actions or interventions prescribed to help achieve the stated goals and objectives.

18. Intervention (Implementation)
Actual performance of the nursing interventions in the plan of care
Includes direct patient care, health teaching, or carrying out ordered medical treatments such as medications or dressing changes
Nurses provide care to achieve established goals of care and then communicate the nursing interventions by documentation and report
The care plan must be flexible and reflect changes in the patient’s health care needs

19. Evaluation
Ongoing process that enables you to determine what progress the patient has made in meeting the goals for care
The outcome criteria provide objective measures for determining the effects of care
Outcomes compared with expected outcomes of patient care to determine whether the goals have been met, partially met, or not met
The plan of care should be reexamined and modified where necessary.
How can the results of an ongoing evaluation be used?

20. Evaluation
Important in individual care, but also provides data on quality of care in health care institution
Quality assurance audits conducted by health care agencies as well as Joint Commission on Accreditation of Healthcare Organizations
American Nurses Association Standards of Care used to determine if nurses have carried out the nursing process as documented in patient records
Areas evaluated by The Joint Commission include the standards of nursing care used, the quality and effectiveness of nursing care, and the organization of the patient care system.
How are nursing audits conducted?

21. Clinical Pathways
Standard care plans developed to set daily care priorities, schedule achievement of outcomes, and reduce length of hospital stays
Include patient outcomes and timelines for the sequence of interventions
Clinical pathways: collaborative and comprehensive; jointly developed by all members of health care team; and cover many aspects of care, not just nursing interventions
What are the benefits of clinical pathways?
There are concerns about the potential for legal liability when there are deviations from pathways (even when justified).

22. Concept Maps
Visual plans of care that illustrate the relationships between and among pathophysiology, signs and symptoms, nursing diagnoses, and collaborative interventions
Used primarily as learning tools to develop comprehensive plans of care

23. Nursing Documentation
Helps achieve continuity of care because it provides for communication among caregivers; a record of patient’s progress
Provides a legal record of care provided and a means to verify services rendered for insurance payments
Patient assessments and observations and all nursing interventions should be charted as a permanent part of the patient’s medical record, which is a legal record.

24. Nursing Documentation
All treatments and care, including medications
Procedures performed at the bedside, on the unit, or inside or outside the facility
Patient’s reaction to procedures
Observations of the patient

25. Nursing Documentation
Subjective and objective signs and symptoms experienced by the patient
Evidence of changes in the patient’s physical, psychosocial, and spiritual needs and status
Any unusual incidents, such as falls or injuries, that occur during the patient’s stay in the health care facility

26. Nursing Documentation
Should be factual, current, complete, organized, and accurate
Writing should be legible, using proper grammar, punctuation, and spelling
Observations stated objectively, describing only what was seen, heard, felt, or smelled
Direct quotations from the patient regarding symptoms are appropriate
With paper charts, each page should have the patient’s name, and the date and time should be noted for each entry.
When should documentation be done?

27. Nursing Documentation
Each time an entry is made, sign with your full name and title
Use only permanent ink, and make no erasures
If you make an error in charting, cross out the entry and write “error” or “mistaken entry,” followed by your initials
Increasingly, patient records are entered and maintained in computerized charting systems.
Some systems allow documentation at the patient’s bedside.
What are the advantages and disadvantages of computerized charting?

28. Documentation Formats
Nurses’ notes
Pages of narrative recordings containing assessment data, interventions carried out by the nurse, and evaluation data collected
Flow sheets
May be graphs of vital signs or tables in which nurses may check or initial boxes indicating activities or care provided
What are some examples of charting approaches?

29. Documentation Formats
Problem-oriented medical record (POMR)
Record keeping that focuses on patient problems rather than on medical diagnoses
Excellent means of communication among the various disciplines that are providing care
The charting is done in a SOAPIER format
S—Subjective; O—Objective; A—Assessment;
P—Plan; E—Evaluation; R—Revision
Each health care provider involved in the care of the patient charts on the same progress notes in the same format.
What information provides a foundation for problems formulated in the POMR?

30. Critical Thinking
Defined as “reflective and reasonable thinking that is focused on deciding what to believe or do”
Tools to seek and apply knowledge
Nursing deals with people in states of change in an environment that is constantly evolving; critical thinking skills allow the nurse to base the plan of care on actual patient data.
How can critical thinking skills be applied to nursing care?

31. Relationship of Critical Thinking to the Nursing Process
The nursing process is a framework for developing, implementing, and evaluating a plan of care
It spells out the patient’s needs and problems, the goals for care, interventions to achieve goals, and how goal achievement will be assessed

32. Relationship of Critical Thinking to the Nursing Process
The nursing process does not flow smoothly from one step to the next, but often moves back and forth between steps
The nursing process is a sequence of steps that should be based on critical thinking
Why should “ready-made” care plans not be used?

33. Characteristics of a Critical Thinker
Curiosity
The desire, not just to know, but to understand how and why, to apply knowledge
Systematic thinking
Uses an organized approach to problem solving, rather than knee-jerk responses
Analytic
Applies knowledge from various disciplines, approaches a problem by examining the parts and seeing how they fit together

34. Characteristics of a Critical Thinker
Open-minded
Willing to consider various alternatives
Self-confident
Sense of assurance that the problem-solving process produces a good conclusion/plan
Maturity
Recognition that many variables are at work in patient situations, and sometimes the best plans do not work
Truth-seeking
Eager to know, asking questions, seeking answers, reevaluates “common knowledge”

35. Critical Thinking Tools
Interpretation
Clarifying meaning of events, data
Analysis
Examining ideas, breaking down into components
Evaluation
Assessing possibilities, opinions, usual practices

36. Critical Thinking Tools
Inference
Deriving alternatives, drawing conclusions
Explanation
Presenting arguments for views, decisions; justifying
Self-regulation
Reconsidering conclusions, recognizing need to make changes