A Student’s Guideline to Using the Critical Thinking Rubric to meet the Performance Objectives in Developing Nursing Care PlansSuffolk Community College

School of Nursing

Susan McCabe

A Continuation of the Project Plan from the Summer Institute the TITLE III grant: “The Development of the Critical Thinking Rubric to Analyze Nursing Care Plans”

What Are the Characteristics of an Excellent Nursing Care Plan?

There are three characteristics that distinguish excellent student performers from their peers.

Evidences adequate inquiry, research and use of best resources.

CHARACTERISTICS OF AN EXCELLENT NCP

Deduces the most accurate human response (diagnostic label) from the data collected.

CHARACTERISTICS OF AN EXCELLENT NCP

Analyzes the human responses and selects the the diagnostic labels that would have the greatest impact on the client’s outcome.

CHARACTERISTICS OF AN EXCELLENT NCP

Evidences adequate inquiry, research and use of best resources.

Meeting the behavioral objective:

How can the student achieve this objective?

The groundwork for an excellent care plan begins with the utilization of inquiry, research and resources at the clinical site.

It begins in preconference when the student receives report.

Preconference exerciseYou receive report on the following client:

79 y/o female admitted for pneumonia, exacerbation of COPD who has CHF by history with the following orders:

nasal cannula oxygen at 2 lpmalbuterol drug nebs q 4hrs and q 2 hours prn IV D51/2 NS at 75 cc/hr Solumedrol 80 mg IVP q 6 hrs ABG’s on room air and electrolytes to be drawn

this AM.

Exercise your inquiry,research and best resources.

Reflect on knowledge and skills79 y/o female admitted for pneumonia,

exacerbation of COPD who has CHF by history with the following orders:

nasal cannula oxygen at 2 lpmalbuterol drug nebs q 4hrs and q 2 hours prn IV D51/2 NS at 75 cc/hr Solumedrol 80 mg IVP q 6 hrs ABG’s on room air and electrolytes to be drawn

this AM.

ASK YOURSELF WHO, WHAT WHY, WHERE, WHEN AND HOW?

Identify your best resources and referencesWhat handbooks would you access

immediately to prepare for caring for your client?

How can each resource facilitate the attainment of knowledge and skills?

• MED/SURG handbook• drug reference• lab test reference• nursing diagnosis handbook• hospital procedure manual

Develop a plan to evidence adequate inquiry and assess your client.

Initial client assessment:LOC: level of consciousnessA: airwayB: breathingC: circulation/bleedingI/O: everything going in/outwound: what does it look like?Pain: present? Scale? Treatment?safety: bed low? Call bell? Siderail?

After performing the initial assessment, gather any additional information you need from the chart and return to perform a focused assessment.

SPECIFIC QUESTIONS RELATED TO THE CHIEF

COMPLAINT AND RELATED

SYSTEMS

The Interview

The Interview

Interview questions should identify the client’s response to their situation

should include both positive and negative findings that you might suspect a client experiencing those stressors could experience

record all the clients responses using all available space

APPROACH TO EXAM

DO YOUR ABC's, THEN

– INSPECTION– PALPATION– PERCUSSION– AUSCULTATION

Don’t just fill in the blanks….Use all available space to communicate the pertinent findings integrating the health assessment framework.

Seek clarification

Check your findings against the what has been previously recorded for the client…..

a variation in the client’s status should be clarified with your best resource on the unit……

your clinical instructor.

Develop a narrative that reflects the “thinking and doing” of the nurse:

the assessment, actions and client response.

Clarify significance of data, actions and client response in post-conference.

Organize your data to perform additional research to prepare the NCP.

Assessment formdaily nursing process planlab data results sheetmedication sheets

INQUIRY, RESEARCH, SOURCES

RESEARCH THE SUBJECTIVE AND OBJECTIVE DATA UNTIL YOU OWN

THE MATERIAL.

DON’T PUT ANYTHING ON PAPER THAT YOU CAN NOT EXPLAIN IN YOUR OWN WORDS.

Develop a reference list

IDENTIFY THE BEST RESOURCES TO FACILITATE YOUR UNDERSTANDING.

Instead of compiling a list of resources that you think are relevant…. Read the references and decide which help

you to grasp the meaning of the client’s situation.

Use a systematic approach to develop a priority list. Challenge assumptions from your research and place it in the context of your client’s unique response.

What is the source of the client’s unique response?

Assessment formdaily nursing process planlab data results sheetmedication sheets

What is the priority list?

A list of diagnostic labelseach label conforms to PES formatdeveloped from the systematic analysis of all the relevant data

Where do I begin?Begin with the stressors that the client is currently experiencing.Consider continuing stressors that the client faces that influence their adaptation to the stressor precipitating the current admission.

What are the stressors?

Examine the following:– admitting diagnosis– previous medical history– previous medications– current medications– current therapies– current procedures

CAN YOU IDENTIFY ANY COLLABORATIVE PROBLEMS THAT

THE CLIENT MAY BE EXPERIENCING?

Accurate nursing diagnosis requires that the nurse effectively cluster data that irrefutably supports the diagnosis.

HOW IS A DATA CLUSTER FORMED?Developed when one piece of data signals

a potential problem

– It may be a positive or negative findingtriggers analysis of inferences identified

– many closely related nursing diagnoses come to mind

leads to a collection of cues (units of information)

– requires inclusion of major defining characteristics

Abnormal units of data may indicate a dysfunctional health pattern

systematically review diagnosis definitions and defining characteristics that relates to the functional health pattern

determine if a data cluster exists to support the diagnosis

HOW DOES A STUDENT NURSE IDENTIFY INFERENCES?

What if you don’t have a data cluster?

You can not use the diagnosis. Additional assessment would be required to ascertain the client’s health status in relation to the suspected dysfunction.

What if you do have a data cluster?

Proceed in creating your diagnostic statement using PES format and add to priority list

What does your priority list include?One part statements

– collaborative problems and syndromes– make sure supporting data is recorded in first

column of NCP form

2 part statements– “risk for” statements

3 part statements– diagnostic label – etiological factor– supporting data

How do I rank my priority sheet?

Consider possible frameworks but remember to consider the context of the client’s current circumstances as it is recorded in the daily nursing process plan.

Organizing framework

Ask yourself how the diagnoses fit according to the following framework?

– Life-threatening concerns– safety concerns– patient concerns– nursing concerns

Maslow’s framework

Basic/ Physical Needs Safety Needs Social Needs Esteem Needs Self Actualization

Assessment frameworkLOC: level of consciousnessA: airwayB: breathingC: circulation/bleedingI/O: everything going in/outwound: what does it look like?Pain: present? Scale? Treatment?safety: bed low? Call bell? Siderail?

Rank diagnoses in the order of the highest priority to the lowest.

Your nursing narrative is your argument to support your selections.

Place a number that corresponds to its rank in front of each diagnosis listed.

NCP#1 Assessment

SUBMIT TO YOUR CLINICAL INSTRUCTOR

– ASSESSMENT FORM– DAILY NURSING PROCESS PLAN– LAB DATA SHEET – MEDICATION SHEET – REFERENCE LIST– PRIORITY NURSING DIAGNOSIS LIST

ENSURE THAT IS COMPREHENSIVE AND COMPLETE.

Review your feedback on your part one assessment to integrate into your next performance.

Successive performances are measured to ensure that you show progression in the performance.

Selecting the appropriate diagnoses

Review the contextual circumstances of your client and determine which of the diagnostic plans would have the greatest impact on the client’s health status.

The care plan format

Demographic informationsupporting datacollaborative problem/nursing

diagnosisoutcomeinterventionsscientific rationaleevaluation

SUPPORTING DATA

THE ACTUAL DATA– Subjective and objective that must be

present in your database; assessment form, daily nursing process plan, medication sheets, lab data, diagnostics.

– Must be major and minor manifestations relevant to the diagnosis

NURSING DIAGNOSIS

Look at your priority list:1 and 2 part statements3 part statement

– Label• NANDA label

– Etiology• Physiologic, situational, treatment

related, environmental, maturational

– Evidencing data

Predicting outcomes

Nurses make statements about what they would like to see the client achieve to manage or resolve the client’s response that triggered the diagnostic label.

OUTCOME CRITERIA

Outcomes are statements that include the following:

– An action verb • a measurable, observable behavior written in

terms of what the client will do/accomplish to resolve or manage the human response

– a time frame • a specific target date/time for achieving the

outcome that can realistically be accomplished

– May require more than one statement

Nurses design plans of care to assist the client in achieving outcomes.

Interventions are nursing actions that directly and indirectly influence client’s health and environment

Characteristics of interventions

Specific actions performed by the nurse the supports the client in:– physiologic functioning

• simple and complex

– behavioral/psychosocial functioning– protection against harm– family unit functioning– effective use of the health care system

ESSENTIAL COMPONENTS OF INTERVENTIONS– Must be linked to the outcome– Are performance based

• What am I going to watch out for?– EX: MONITOR OR ASSESS

• What am I going to do?– EX: INSTRUCT, ASSIST, ENCOURAGE, SUCTION,

POSITION

• How does the medical plan impact the client’s response and how can I integrate it?

– ADMINISTER, IRRIGATE, REGULATE, MAINTAIN

• Who else needs to be consulted?– CONSULT MD, RESPIRATORY, DIETARY, PT

INTERVENTIONS

– LINK TO OUTCOMES– MULTIPLE INTERVENTIONS MAY BE

REQUIRED TO ACHIEVE AN OUTCOME– NEED TO DESCRIBE WHAT WILL BE

DONE, IN TERMS OF THE CLIENT, AND CRITERIA FOR CONSULTATION

SCIENTIFIC RATIONALE

– This should be a succinct statement that reflects the synthesis of your understanding of the reasoning behind the interventions inclusion into the plan of care.

– Based on researching the references cited.

EVALUATION

– Subjective And Objective Data That Measures The Client’s Response To The Plan

– No Such Thing As Pending Data– Look At Your Outcome And

Interventions And Determine What Data Reports The Client’s Response

Sample intervention/evaluation respirations even and

unlabored, rate 18, pulse oximetry 98% on 2 lpm humidified nasal cannula. Lungs bilateral rhonchi

occasional cough productive for thin, scant yellow sputum. HOB elevated 45 deg, Instructed to cough and deep breath, states understanding, return demonstration given. po fluids encouraged tolerated 500cc.

Monitor respiratory status, presence of adventitious breath sounds, ineffective cough,presence of sputum; color consistency, quantity.

Administer humidified O2 as ordered and mon pulse oximetry

position client HOB elevated instruct client in C&DB

exercisesencourage 2000 cc fluid/24

hours

CONCLUSION

Behavioral objectives for student performance in nursing care plans can be met through the development of critical thinking skills and dispositions that are evident in every step of the nursing process and the written record known as nursing care plans.

Evidence adequate inquiry, research and use of best resources.

CREATING AN EXCELLENT NCP

Deduce the most accurate human response (diagnostic label) from the data collected.

CREATING AN EXCELLENT NCP

Analyze the human responses and selects the the diagnostic labels that would have the greatest impact on the client’s outcome.

CREATING AN EXCELLENT NCP

The student plans care for the client that will:

Facilitate achievement of outcomes,

Prescribe specific nursing actions,

Use scientific reasoning based on the latest literature.

The student will account for the client’s response:

Through the organization of subjective and objective data that measures the client’s response to the plan.