Separating the Professional from the Technical

“the active, organized, cognitive process used to examine one’s own thinking and the thinking of others”

Using reflection, intuition, and previous experiences to make sound decisions

Requires a habit of asking questions, remaining well informed, a willingness to reconsider, and avoiding premature decision making

Knowledge base◦ Theoretical ◦ Experiential

Experience◦ Practice making decisions

Technical Skills & Competencies Attitudes and behaviors

•Self aware•Genuine / authentic•Effective communicator•Curious & inquisitive•Alert to context•Analytical & insightful•Logical and intuitive•Confident & resilient•Honest•Responsible & autonomous

•Careful & prudent•Open & fair minded•Sensitive to diversity•Creative•Realistic and practical•Reflective & self-corrective•Proactive•Courageous•Patient & persistent•Flexible•Improvement oriented

The Nursing Process: a systematic problem solving approach consisting of;◦ Assessment◦ Diagnosis◦ Planning◦ Implementation◦ Evaluation

Nursing involves both thinking and doing Nursing deals with complex issues

◦Brings togetherCritical thinkingNursing processNursing knowledgePatient situation

◦Types of AssessmentComprehensive

FocusedSpecial needs

Initial Ongoing

Types of Data◦ Subjective

◦ Objective

Sources of Data◦ Primary data

Client

◦ Secondary data Family Health Records Health Team Members

Methods of collection◦ObservationUse all 5 senses

◦Physical assessment

◦InterviewHealth history

Performed after nursing history Collection of objective data

◦ Ht., Wt., V.S.◦ General Survey◦ Head to toe exam

Inspection Palpation Percussion Auscultation Olfaction

Biographical Data Reason for Seeking Health Care / Chief

complaint ◦ Client’s Expectations

History of Present Illness Past Health History Family History / social history Medications Review of body systems

To ensure data is ◦ accurate◦ Complete◦ Factual◦ And you are not jumping to conclusions

When to validate◦ Subjective and objective data do not agree◦ Patient’s statements differ at different times◦ Data falls outside normal range

Systematic Usually controlled by agency forms

◦ Body systems framework◦ Maslow’s Hierarchy of Needs◦ Gordon’s functional patterns◦ Orem’s Self care model◦ Roy Adaptation Model◦ NANDA nursing diagnosis Taxonomy II

Organizing data into meaningful clusters

A set of signs or symptoms grouped together into logical order

Groupings of associations

Helps you recognize significant cues

Utilizes critical thinking to

◦Judge the value or significance of the data

◦Validate and verify assumptions with client and other health care team members

Identify patterns in data and draw conclusions about client’s status

Describes client’s actual or potential response to a health problem

A statement of client health that nurses can identify, prevent, or treat independently

Stated in terms of unique human responses to diseases, injuries, or stressors

Must be accurate because it provides direction for nursing care

Actual (3-part statement)

◦ Presently exists

Risk (2-part statement)

◦ Likely to develop in vulnerable patient

Possible (2 or 3- part statement)

◦ Suspect on intuition but don’t have enough data yet

Syndrome (1 part statement)

◦ Collection of nursing diagnoses that occur together

Wellness (1-part statement)

◦ Not a health problem, wants to move to higher level of wellness

Diagnostic Label (title or name)◦ Approved by NANDA

Related Factors◦ Etiology must be in nurses domain to intervene◦ Don’t use medical diagnoses

Defining Characteristics◦ Cues from assessment data ◦ must support diagnosis

Eg. Impaired mobility R/T lack of peripheral sensation AEB inability to walk from bed to chair.

Data collection◦ Omitted, incomplete, inaccurate, disorganized

Data analysis & interpretation◦ Inaccurate interpretation of cues, conflicting cues,

incorrect judgments of inferences Data clustering

◦ Incorrectly clustered or not clustered at all Diagnostic Statement

◦ Problem & etiology must be in scope of nursing to treat

Identify client’s response not medical diagnosis

One symptom is insufficient for problem identification

Nursing interventions directed at correcting etiology of problem

Identify client response to equipment not the equipment itself

Client problems not nurse problems Develop in cooperation with client

Nursing diagnosis◦ Defines nursing needs of clients related to the

medical diagnoses

Medical Diagnosis◦ Reflects specific disease, illness, or injury ◦ Goal – prescribe treatment

Place in order of importance or urgency

Maslow’s Hierarchy of Human Needs◦ Physiological◦ Safety and security◦ Love and belonging◦ Self-esteem◦ Self-actualization

A,B,C’s Nursing Process

Client centered goals / outcomes◦ Specific measurable objective◦ Are precise, descriptive, clearly stated◦ Reflects highest level of wellness◦ Should be realistic◦ Observable client behavior◦ Measurable criteria for each goal◦ Projected time frame for goal achievement◦ Provide a guide for selecting interventions

Short term goals Achieve in hours or days, less than 1 week

Long term goals Achieved over weeks or months

Subject◦ The client

Action verb◦ Action that will be performed by client

Performance criteria◦ Specific measurement to be evaluated

Target time◦ When action should be achieved

Special conditions◦ Amt. of assistance, what equipment, resources

needed

Client centered… Singular factors/ criteria… Observable factors… Measurable factors… Time limited factors… Mutual factors… Realistic factors…

Serves as Written guidelines for client care Communicates care Enhances continuity Organizes information – promotes efficiency Involves client and family Meets requirements of accrediting agencies

Care plans help students learn problem solving, skills of written communication, organizational skills, and application of theory

AKA Nursing ◦ Actions◦ Measures◦ Strategies◦ Activities

◦ Actions based on clinical nursing judgment and knowledge that nurses perform to achieve client outcomes

◦ Include activities of observation/assessment, prevention, treatment, & health promotion

Independent◦ Nurse initiated interventions◦ In realm of independent nursing practice◦ No MD order required

Dependent◦ Physician initiated interventions◦ Require MD orders

Collaborative (interdependent) interventions◦ Coordination of multiple professionals

Include activities of Observation/assessment Prevention Therapeutic Treatments Health promotion Activities of daily living Teaching Discharge planning

Flow from Client goals/outcomes / orders

Individualize standardized interventions

Nursing Orders◦ Instructions on care plan describing

implementation of interventions Include

Date Subject Action verb Times and limits Signature

Standing Orders Protocols Critical Pathways Evidence Based Practice

Nursing action nonspecific

Fail to indicate frequency

Fail to indicate quantity

Fail to indicate method

Fail to indicate person to perform

Implementation The action phase of the nursing process You will perform or delegate planned

interventions Implementation ends when you record the

nursing actions on chart◦ Evolves into evaluation as you record resulting

client responses

Check your knowledge and abilities Organize your work Prepare the patient Implement the plan Coordinate/collaborate

◦ Delegate appropriately Right task Right circumstance Right person Right directions / communication Right supervision

Planned Ongoing

◦ Does not end the nursing process Systematic

Make judgments about◦ Client’s progress toward expected outcomes/goals◦ Effectiveness of nursing care plan◦ Quality of nursing care delivered

Ongoing evaluation◦ At each contact with patient

Intermittent evaluation◦ At outcome evaluation specified times

Terminal evaluation◦ At time of discharge

Review Outcomes Collect Reassessment Data Judge Goal Achievement

◦ Achieved (met)◦ Partially achieved (partially met)◦ Not achieved (unmet)

Record evaluative statement Revise care plan if indicated

◦ Begin with assessment data and go through entire nursing process

Written evidence of interactions◦ Health professionals◦ Clients◦ Families◦ Health care organizations◦ Diagnostic tests◦ Treatments◦ Education◦ Client results/responses

Correct client record Client name on each page Document immediately Date and time each entry Sign each entry with name and professional

credentials No space between entries Never change another’s entry Use “quotes” for client statements Chronological order

Use appropriate vocabulary / terminology Only approved abbreviations / symbols Use organized and logical sequence State only factual not inferences Use correct spelling, legible writing Protect client confidentiality by not releasing

records to anyone without patient permission Write neatly, legibly, & in ink Use concrete specific terms Follow agency guidelines

Source-Oriented Records◦ Separate sections for each discipline

Problem-Oriented Records◦ Consists of database, problem list, plan of care, &

progress notes

Narrative

SOAP

PIE

Focus

Charting by exception

Computerized