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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