Nursing Process: Critical Thinking, Clinical Judgment, Evidence-Based Practice

Nursing Process, Critical Thinking, Clinical Judgment, Evidence Informed Practice Readings: pg. 187-215, 304-323 (Ch 10 + 16) Five Phases of the Nursing Process (pg 187-215) - There are 5 steps in the nursing process: assessment, nursing diagnosis, outcomes/planning, implementation, and evaluation (ADPIE) Critical Thinking and Clinical Reasoning - As nurses navigate the nursing process, they draw on critical thinking and clinical reasoning skills to assess, analyze, and interpret information. Critical thinking and clinical reasoning are guided by the client’s situation and needs, the nurses’ knowledge, skill and experience, theory and evidence, professional standards, policies and procedures, ethics, as well as safety and quality considerations Assessment - The nursing process begins with assessment where data is collected, organized, validated, and documented. - Subjective vs. objective data - Gathering data and compiling a health history through client interviews, a physical examination, and analysis of diagnostic and laboratory results, as well as other sources of data such as health records and research - Collecting data from multiple sources provides a holistic perspective of the client’s past and current health status and may identify factors that could influence the client’s health trajectory - 4 types of assessment: - - - - - - - Initial assessment: completed most often when the nurse meets the client for the first time - Focused assessment: gathers specific details about the presenting concern - Ongoing assessment: helps nurses determine whether the condition has improved, worsened, or stayed the same - Emergency assessment: used in a trauma or emergency situation Whenever you are assessing health information, it is important to consider whether your request is relevant to the care you are providing, and if necessary, whether you have obtained proper consent - It is important to note that data is not static, but constantly changing. The most recent data should be compared with baseline data or previously collected data if they are available There are 4 common ways nurses collect data. They may conduct an interview, complete forms including validated assessment tools, perform a physical assessment, or review the client’s diagnostic and laboratory results - Other ways to collect data include interviews with family members or significant others, from other interprofessional team members, clinical records, or using relevant literature and research Interviews provide an opportunity for the nurse and client to exchange information and form a therapeutic relationship. Every encounter provides an opportunity to assess your client’s condition across multiple dimensions. Nurses will use interview data in conjunction with their own assessment findings to determine the appropriate plan of care. - In the initial interview, the nurse will introduce themselves to the client and explain the role of the interview process - You need to be respectful, empathetic, and trustworthy, while maintaining appropriate professional boundaries and awareness of the power differential that exists between you and the client Nursing judgment occurs when the nurse is able to make decisions using his/her nursing knowledge and experience in conjunction with what he or she knows about the client - Throughout the interview, the nurse observes and uses both verbal and nonverbal communication. The interview may begin with open-ended questions to allow the client to give as much information as possible, and lead with closeended questions to focus on specific areas of interest. - Therapeutic communication skills are used to build rapport, exchange information, plan treatment, and promote client well-being Assessment tools and forms: intake and health history questionnaires, checklists, risk and pain assessment tools, demographic information, genograms and ecomaps Nurses conduct a physical assessment to gather more information about areas of concern or assess overall health - This may include taking vital signs and a head-to-toe assessment using observation, inspection, auscultation, palpation, and percussion Documentation of data is just as important as organizing the information. It's important to be able to differentiate between significant and nonsignificant data Diagnosis - Formulating a diagnosis is the second phase of the nursing process and involves analyzing the data, identifying health problems and risks as well as strengths, and formulating diagnostic statements - A medical diagnosis relates primarily to the disease process, pathology, or condition and has implications for medical treatment - A nursing diagnosis is a clinical judgment that describes the client, family, group, or community’s response to actual and potential health conditions or life processes - Diagnoses related to health problems, health risks, and health promotion - One of the limitations of using a standardized nursing taxonomy for diagnoses is that these are not widely used outside of the professional practice of nurses, leading to confusion for other interprofessional team members about terminology and interventions. - Difficult to address the individuality of the client, or account for a wide range of variables such as age, gender, culture, additional health concerns, spiritual beliefs, socioeconomic status, and psychosocial supports Outcomes/Planning - outcomes/planning is the third stage of the nursing process. This stage includes the steps taken by the nurse, interprofessional team, client, and family to develop goals, identify desired health outcomes, formulate care plans, prioritize appropriate nursing interventions, and coordinate necessary resources - Planning begins when the nurse first meets the client and continues until the patient is discharged or care has been transferred - There are 3 types of planning: - Initial planning: part of the admission assessment and identifies what actions are required to move forward in providing client care - Ongoing planning: is continuous and involves adapting client care in response to new information obtained through assessment and evaluation - Discharge planning: anticipates and plans for the client’s needs as he or she transitions between health services as well as independent living - The planning phase of the nursing process begins with prioritizing the diagnoses (care needs) of the client - Other factors that need to be considered include the acuity of the client’s situation, the client’s wishes and preferences, and available resources - When setting priorities, it is important to consider the nurse’s scope of practice, the client’s condition, needs and capabilities, and related professional policies and guidelines - Maslow’s hierarchy of needs: five categories including physiological, safety, love and belonging, esteem, and self-actualization - Synthesis is the process of combining assessment data, nursing knowledge, and clinical experience to determine provision of care - Frequently, nurses collaborate with others to plan and deliver effective care. The health care team may include the client and their family, physician or nurse practitioner, and - - other health care providers. Collaboration provides an opportunity to develop a holistic care plan After the priorities of care have been determined, measurable (SMART) goals can be established to assist the client to move toward wellness - Specific - Measurable - Attainable/Achievable - Relevant/Realistic - Time-limited Nursing care plans are documents that outline the care that is provided for the client, family, or community. The care plan is holistic and includes priority problems/nursing diagnosis, nursing interventions, and client-focused outcomes - A nursing care plan will reflect the needs of the client and the nurse’s assessment data and clinical judgment, the nurse’s scope of practice, and the health care organization’s guidelines and policies Implementation - Implementation is the fourth phase in the nursing process. In the implementation phase, the nurse carries out and documents the interventions needed to achieve the client’s health-related goals - Involving reassessing the client, determining resources that are required, implementing the nursing interventions, supervising any delegated care, and documenting all of the nursing activities - Implementation skills may include critical thinking, psychomotor dexterity, therapeutic communication techniques, and relational skills - Direct interventions would also include lifesaving measures such as CPR or first aid - Some interventions will focus on the signs and symptoms of the diagnosis, whereas others will be more specific to altering risk factors. Your focus will be determines when you prioritize your diagnoses, goals, and desired outcomes Discharge and Transition Planning - Assessment of the client’s discharge or transition needs should begin at the point of admission and continue throughout the hospital stay - Client’s may face limitations related to their illness. If the acuity of the client or the complexity of their circumstances increases, it may be necessary to delay their discharge from hospital until home care is arranged - Nurses provide holistic care by determining what resources the patient needs and/or the consider if the cost of the resources is affordable for the client and/or family Evaluation - The nursing process is dynamic and nonlinear, so although evaluation is considered the final phase of the nursing process, evaluation is often ongoing. Evaluation is necessary to determine whether the nurse’s actions were effective in meeting the client’s goals and achieving the anticipated outcomes - - During the evaluation phase, the nurse will also identify any unintended outcomes and determine if any changes to the plan are required to achieve any unmet goals - Understanding how the data fits together not only helps you identify if the goal has been met but also provides rationale for the outcome To evaluate the effectiveness of the care plan, the nurse would review the client’s response to all of the interventions and the resources that were used What is Thinking? (pg 304-323) - The common feature of thinking is that there is conscious engagement about an idea, thought, or perceived problem - Inductive reasoning: refers to specific events used to form border generalizations - Deductive reasoning: refers to generalizations used to create specific conclusions - Critical thinking is a purposeful process that is reflective, consecutive, and intentional, and goes beyond recognition or a general thought - General thinking is not classified as critical thinking tends to be biased and uninformed by one’s significant level of past knowledge or experience - Critical thinking can be described in various ways including as a mode of thinking about any subject, content, context, or issue in which the thinker endeavors to improve the quality of his/her thinking by applying intellectual standards to the thinking process - Based on intellectual values: clarity, precision, consistency, relevance, sound evidence, good reasons, depth, breadth, and fairness - Critical thinking helps to transform knowledge into understanding and prompts action, or nursing practice which is supported by the nurse’s understanding of the knowledge and the nursing encounter. Without critical thinking, a deeper understanding of knowledge would not occur, leaving nursing care essentially ineffective Recognizing Critical Thinking at Work - Critical thinking is educated and triggered by curiosity and inquisitiveness - The perfections of thoughts include: - Clarity, precision, specificity, accuracy, relevance, consistency, logicalness, depth, completeness, significance, fairness, and adequacy for the purpose at hand - Self-awareness: being attentive to one’s inner qualities such as being inquisitive or open-minded as well as having a good grasp of one’s biases and values as they relate to certain situations and contexts - Self-direction: being able to initiate thinking and actions without cues or interference from others. Why Do We Need Critical Thinking? - The purposes of critical thinking can be categorized into social, economic, political, ethical, and moral aspects - Critical thinking helps to bring awareness about one’s own and other’s feelings and thinking. More specifically, critical thinking acts as an impetus for effective - communication by fostering open and honest dialogue between people. This can be termed intellectual empathy By thinking through situations using analysis, interpretation, evaluation and reflection, nurses can enhance their understanding of the complex factors that affect clients and their families. Critical thinking can be used to effectively plan and implement nursing care. Developing Critical Thinking - Reflection is at the heart of developing critical thinking. It is the activity in which individuals stop and think about events, situations, or interactions, either in the moment or after they have occurred. - Reflective thought: active, persistent, and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends… it includes a conscious and voluntary effort to establish belief upon a firm basis of evidence and rationality - Understanding ourselves is an important element in developing critical thinking. If we are aware of our own values and the lens that we create using our thought and perceptions, we can better understand other’s values - To be self-aware and understand how one’s thought are formed, it is necessary to be aware of one’s assumptions and whether these assumptions are based on truth and reason - Ask yourself why you think and act the way you do - Writing is an important way to organize and communicate thought processes. Critical thinking can be better developed through analytical, argumentative, and reflective writing, all of which can foster systematic and higher-level thought through the process of developing ideas and supporting them with credible, relevant resources. Using Research to Inform Thinking and Action - Evidence: - Support for a position or argument - Information to support our beliefs - A basis for making inferences - Research, evaluating sources of evidence, and reading critically are important things to consider when gathering information - Critical thinking in nursing practice courses requires learning, understanding, and application of new knowledge. Because action and doing are important aspects of critical thinking, nursing practice courses provide real situation and contexts in which to use critical thinking