Download MS1 Ch 2

Medical-Surgical Nursing:
Concepts & Practice
3rd edition
Chapter 2
Critical Thinking and the Nursing Process
Copyright © 2017, Elsevier Inc. All rights reserved.
Theory Objectives



Illustrate how critical thinking affects clinical
judgment.
Explain what characteristics are necessary to
think critically.
Correlate how problem solving and decision
making are a part of critical thinking.
Copyright © 2017, Elsevier Inc. All rights reserved.
2
Theory Objectives (Cont.)



Discuss the LPN/LVN standards for medicalsurgical nursing practice.
Explain three fundamental beliefs about
human life as the basis for nursing process.
Distinguish how critical thinking, clinical
reasoning, and clinical judgment are applied
to the nursing process.
Copyright © 2017, Elsevier Inc. All rights reserved.
3
Clinical Practice Objectives



Select factors that influence critical thinking
during patient care.
Provide a clinical example of how nursing
process is used in the care of medicalsurgical patients.
Demonstrate each of the following techniques
of physical examination: inspection and
observation, olfaction, auscultation, and
percussion.
Copyright © 2017, Elsevier Inc. All rights reserved.
4
Clinical Practice Objectives (Cont.)



Include the patient in formulation of the
nursing care plan.
Use clinical reasoning to prioritize care for a
specific patient.
Prepare a prioritized list for beginning-of-shift
assessment for a specific patient.
Copyright © 2017, Elsevier Inc. All rights reserved.
5
Critical Thinking and Clinical
Judgment



Purposeful, informed, and outcome focused
Principles of nursing process and the
scientific method
Expanding thinking beyond the obvious
Copyright © 2017, Elsevier Inc. All rights reserved.
6
Critical Thinking




A method for solving problems
Evaluate ideas, construct plans, and
determine desired outcomes
Incorporates the scientific method and uses
clinical reasoning to make reliable
observations and to draw sound conclusions
from obtained data
Clinical judgment is the result of critical
thinking applied to clinical situations.
Copyright © 2017, Elsevier Inc. All rights reserved.
7
Critical Thinking and Clinical Judgment
(Cont.)


Critical thinking is at its best when the brain is
purposefully engaged.
While listening to a shift report, pay attention
to what the nurse is saying and think about
how you will apply the information you have
gained.
Copyright © 2017, Elsevier Inc. All rights reserved.
8
Factors That Influence Critical Thinking
and Nursing Care



Attitude
Communication skills
Problem solving and decision making
Copyright © 2017, Elsevier Inc. All rights reserved.
9
Copyright © 2017, Elsevier Inc. All rights reserved.
1
Problem Solving and Decision Making



Incorporating scientific knowledge and
research into nursing requires a consistent,
logical method to solve problems.
Define the problem, gather information,
analyze the information, and develop
solutions.
Next a decision is made about which solution
to use, and then implementation of the
solution occurs.
Copyright © 2017, Elsevier Inc. All rights reserved.
11
Integrating Critical Thinking and the
Nursing Process




Critical thinking, clinical reasoning, and
clinical judgment are integral to use of the
nursing process.
Essential to know the boundaries of the role
of the LPN/LVN in your state
LPN/LVN scopes of practice stipulate a
directed role under the supervision of an RN.
Scopes of practice differ in the areas of care
planning, assessment, intravenous therapy,
teaching, and delegation from state to state.
Copyright © 2017, Elsevier Inc. All rights reserved.
12
Nursing Process





Provides a way to make changes in patient
care if progress is not being made
Builds on a patient’s strengths
Creates a partnership between nurse and
patient
An orderly way to assess a patient’s response
to current health status and to plan,
implement, and evaluate patient responses to
nursing care
The goal is to alleviate, minimize, or prevent
real or potential health problems.
Copyright © 2017, Elsevier Inc. All rights reserved.
13
Applying Standards in Medical-Surgical
Nursing

Five basic steps in the nursing process:





Assessment
Nursing diagnosis
Planning
Implementation
Evaluation
Copyright © 2017, Elsevier Inc. All rights reserved.
14
Assessment (Data Collection)

The purpose of data collection is to have a
relevant database from which patient
problems and potential problems may be
identified.
Copyright © 2017, Elsevier Inc. All rights reserved.
15
A Complete Database


Includes a thorough health history, physical
assessment, psychosocial assessment, and
cultural-spiritual assessments
Includes subjective and objective data


Subjective data—data that the patient gives that
cannot be seen or felt by another, such as pain
Objective data—data that can be verified by sight,
smell, touch, or sound
Copyright © 2017, Elsevier Inc. All rights reserved.
16
Sources of Information





Admission forms
Focused assessments
Interview
Physical assessment
Chart review
Copyright © 2017, Elsevier Inc. All rights reserved.
17
Chart Review

Face sheet provides demographic data such
as address, marital status, insurance
coverage, age, date of birth, occupation,
significant others, and emergency contact
information.
Copyright © 2017, Elsevier Inc. All rights reserved.
18
Chart Review (Cont.)

Physician’s history, physical examination,
progress notes, and results of diagnostic tests
give an overview of the patient’s total health
status and provide a summary of current
health problems and progress toward
resolving them.
Copyright © 2017, Elsevier Inc. All rights reserved.
19
Chart Review (Cont.)

Allergy information should be identified as
part of the admission information and
displayed prominently on the front of the chart
and at other locations as required by the
facility’s policies and procedures.
Copyright © 2017, Elsevier Inc. All rights reserved.
20
Chart Review (Cont.)


Physician’s orders provide a clue as to the
plan for that day.
Medication profile sheets or the medication
administration record (MAR) lists the routine
and as-needed (PRN) medications and
provides documentation of medication
administration.
Copyright © 2017, Elsevier Inc. All rights reserved.
21
Chart Review (Cont.)


Consultation sheets or nursing
documentation includes narrative notes and
flow sheets that describe care provided to the
patient and the patient’s response to that
care.
Reviewing the nursing documentation
provides a comprehensive picture of the
patient’s needs and will assist in preparing for
beginning patient care.
Copyright © 2017, Elsevier Inc. All rights reserved.
22
Older Adult Care Points

Plan extra time for an interview with a patient
who is older.



An older person who is ill may think and speak
more slowly than expected and often has a longer
health history to relate than does a younger
person.
Complete a medication reconciliation form to
identify and prevent polypharmacy.
Check allergies.
Copyright © 2017, Elsevier Inc. All rights reserved.
23
Audience Response Question 1

The nurse notes that the patient is on longterm anticoagulant therapy. What patient
statement(s) would strongly correlate with
excessive anticoagulant therapy? (Select all
that apply.)
1.
2.
3.
4.
5.
“I have noticed some blood streaking in my
bowel movements.”
“I have been embarrassed by constant,
uncontrollable gassiness.”
“My urine has been cloudy with occasional clots.”
“I bruise easily whenever I bump into anything.”
“Flossing my teeth has been painful and bloody.”
Copyright © 2017, Elsevier Inc. All rights reserved.
24
Health Insurance Portability and
Accountability Act (HIPAA)

Any protected health information from a
patient’s chart must be carefully guarded
Copyright © 2017, Elsevier Inc. All rights reserved.
25
Prioritization


Prioritizing includes identifying tasks that are
urgent and tasks that can wait
After you receive your assignments:






Review the patient’s chart.
Look up required drug information.
List focused assessments.
List procedures.
Attend report and make additional notes and
question what you do not understand.
Make rounds.
Copyright © 2017, Elsevier Inc. All rights reserved.
26
Diagnostic Tests








White blood cell count
Red blood cell count
Hemoglobin
Hematocrit
Platelet count
Glucose
Hemoglobin A1C
Thyroid-stimulating hormone
Copyright © 2017, Elsevier Inc. All rights reserved.
27
Nursing Diagnoses


General statements that label patient
problems. They are linked with the etiology
(cause) and evidence (signs and symptoms)
of the problem
Standard stems are published by the North
American Diagnosis Association International
(NANDA-I)
Copyright © 2017, Elsevier Inc. All rights reserved.
28
Nursing Diagnoses & Medical Diagnoses


The physician is concerned with health
problems that can be treated with surgery,
medications, and other forms of therapy
provided or prescribed by the physician.
Nursing diagnoses identify the patient’s
response to an illness or a health condition.
Copyright © 2017, Elsevier Inc. All rights reserved.
29
Priority Setting
Copyright © 2017, Elsevier Inc. All rights reserved.
30
Audience Response Question 2

What is considered critical in assessing sleep
disturbance of the patient? (Select all that
apply.)
Family history of sleep disorders
2. Rituals associated with sleep
3. Feelings of restfulness
4. Diet choices
5. Urinary habits
Answer : 2, 3, 4 and 5
1.
Copyright © 2017, Elsevier Inc. All rights reserved.
31
Planning

Goals, expected outcomes, and nursing
interventions



Goals state a general intent about what the patient
will achieve.
Expected outcomes describe a specific result
expected at a certain point in time.
Nursing interventions are nursing actions and
patient activities chosen to achieve the goals and
expected outcomes.
Copyright © 2017, Elsevier Inc. All rights reserved.
32
Implementation


LPN/LVN standards require providing care
within the scope of practice to accomplish
established goals.
Individualize standardized plans.
Copyright © 2017, Elsevier Inc. All rights reserved.
33

What nursing action(s) should be
implemented if the patient has a nursing
diagnosis of Imbalanced nutrition: less than
body requirements related to poor dental
condition? (Select all that apply.)
1.
2.
3.
4.
5.
Encourage fluid intake if not contraindicated by
the medical condition.
Inspect oral cavity and condition of mucous
membranes and teeth.
Assist with swallowing.
Initiate speech therapy and dietitian consult.
Monitor daily caloric intake and weekly weights.
Copyright © 2017, Elsevier Inc. All rights reserved.
34
Staff Communication



Interstaff communication
Charting and electronic health record
Report
Copyright © 2017, Elsevier Inc. All rights reserved.
35
36
Evaluation


A comparison of actual outcomes of patient
care with the expected outcomes
Documented data demonstrate a patient’s
progress.
Copyright © 2017, Elsevier Inc. All rights reserved.
37
Interdisciplinary (Collaborative) Care
Plans






Medical diagnosis
Shared observations
Problem list
Shared care plan
Team approach
Progress reporting
Copyright © 2017, Elsevier Inc. All rights reserved.
38