handout nursing process

Joannes Paulus T. Hernandez, B.S.H.B.,

B.S.N., R.N. 1

Joannes Paulus T. Hernandez, BS (Human) Biology, BS Nursing, R.N.

Nursing Process, Nursing Skills, and Clinical Reasoning

The Nursing Process

• One of the major guidelines for nursing practice

• Helps nurses implement their roles

• Integrates art and science of nursing

• Allows nurses to use critical thinking

• Defines the areas of care that are within the domain of nursing

• It is a systematic method that directs the nurse and client as they together determine the need for nursing care, plan and implement the care, and evaluate the result.

Historical Development of the Nursing Process

• 1955 — nursing process term was first used by Lydia Hall

• 1960’s — specific steps delineated

• 1967 — Yura and Walsh published first comprehensive book on nursing process

• 1973 — ANA Congress for Nursing Practice developed Standard of Practice

• 1982 — state board examinations for professional nursing uses nursing process as organizing concept

Characteristics of the Nursing Process

• Systematic — part of an ordered sequence of activities

• Dynamic — great interaction and overlapping among the five steps

• Interpersonal — human being is always at the heart of nursing

• Outcome oriented — nurses and patients work together to identify outcomes

• Universally applicable — a framework for all nursing activities

Characteristics of the Nursing Process(Continued)

It is a GOSH approach for efficient and effective provision of nursing care.

G – oal-oriented

O – rganized

S – ystematic

H – umanistic care

Problem solving and the Nursing Process

• Trial-and-error problem solving

• Scientific problem solving

• Intuitive thinking

• Critical thinking


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Benefits of the Nursing Process

• Patient

– Scientifically based, holistic individualized patient care

– Continuity of care

– Clear, efficient, cost-effective plan of action

• Nurse

– Opportunity to work collaboratively with other healthcare workers

– Satisfaction of making a difference in lives of patients

– Opportunity to grow professionally

Five Steps of the Nursing Process

Five Steps of the Nursing Process

• Assessing — collecting, validating and communicating of patient data

• Diagnosing — analyzing patient data to identify patient strengths and problems

• Planning — specifying patient outcomes and related nursing interventions

• Implementing — carrying out the plan of care

• Evaluating — measuring extent to which patient achieved outcomes

Overview of the Five Steps of the Nursing Process: ASSESSING

Overview of the Five Steps of the Nursing Process: ASSESSING

It is the systematic and continuous collection, validation, and communication of client data as compared to standard.

• Activities:

1. Collection of data

2. Validation of data – data confirmation/comparing to standards

3. Organizing data

4. Analyzing data

5. Recording/documentation of data

• Types of data:

1. Subjective data (symptoms) – described by person experiencing it

2. Objective data (signs) – can be observed and measured

• Sources of data:

1. Primary Data – data directly gathered from the client

2. Secondary data – data gathered from client’s significant others, client’s medical records, patient’s chart, other members of the health team, and related health care literature

• Methods of collecting data:

1. Interview – a planned communication with the client

2. Observation – the use of five senses and instruments

3. Physical Assessment – assessment for objective data and is focused primarily on the client’s functional abilities

Assessing is primarily focused on the client’s response to health problem.

Four Types of Nursing Assessments

• Comprehensive initial

• Focused

• Emergency

• Time-lapsed


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Comprehensive Initial Assessment

• Performed shortly after admittance to hospital

• Performed to establish a complete database for problem identification and care planning

• Performed by the nurse to collect data on all aspects of patient’s health

Focused Assessment

• May be performed during initial assessment or as routine ongoing data collection

• Performed to gather data about a specific problem already identified, or to identify new or overlooked problems

• Performed by the nurse to collect data about the specific problem

Emergency Assessment

• Performed when a physiologic or psychological crisis presents

• Performed to identify life-threatening problems

• Performed by the nurse to gather data about the life-threatening problem

Time-Lapsed Assessment

• Performed to compare a patient’s current status to baseline data obtained earlier

• Performed to reassess health status and make necessary revisions in plan of care.

• Performed by the nurse to collect data about current health status of patient

Establishing Assessment Priorities

• Health orientation

• Developmental stage

• Need for nursing

Medical vs. Nursing Assessments

• Medical assessments

– Target data pointing to pathologic conditions

• Nursing assessments

– Focus on the patient’s response to health problems


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The Skill of Nursing Observation

• Determines the patient’s current responses (physical and emotional)

• Determines the patient’s current ability to manage care

• Determines the immediate environment and its safety

• Determines the larger environment (hospital or community

Four Phases of a Nursing Interview

• Preparatory phase

• Introduction

• Working phase

• Termination

Purpose of a Nursing Physical Assessment

• Appraisal of health status

• Identification of health problems

• Establishment of a database for nursing intervention

Successful Interview Techniques

• Focus on the patient during the interview

• Listen to the patient attentively

• Ask about patient’s main problem first

• Pose questions and comments in appropriate manner

• Avoid comments and question that impede communication

• Use silence and touch appropriately

Five Parts of Communication Process (Berlo)

• The stimulus or referent

• The sender or source of message (encoder)

• The message itself

• The medium or channel of communication

• The receiver

Four Levels of Communication

• Intrapersonal

• Interpersonal

• Small-group

• Organizational


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Roles of Group Members

• Task-oriented — focus on work to be done

• Maintenance — focus on well-being of people doing work

• Self-serving — advance the needs of individual members at group’s expense

Forms of Communication

• Verbal (language)

• Nonverbal (body language)

– Facial expressions

– Posture, gait

– Gestures

– General physical appearance

– Mode of dress and grooming

– Sounds

– Silence

Factors Influencing Communication

• Developmental level

• Gender

• Sociocultural differences

• Roles and responsibilities

• Space and territoriality

• Physical, mental, and emotional state

• Environment

The Helping Relationship

• Does not occur spontaneously

• Characterized by an unequal sharing of information

• Built on the patient’s needs

Characteristics of the Helping Relationship

• Dynamic

• Purposeful and time limited

• Person providing assistance is professionally accountable for the outcomes

Phases of the Helping Relationship

• Orientation phase

• Working phase

• Termination phase


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Goals of the Orientation Phase

• Establish tone and guidelines for the relationship

• Identify each other by name

• Clarify roles of both people

• Establish an agreement about the relationship

• Provide the patient with orientation to the healthcare system

Goals of the Working Phase

• Work together to meet the patient’s needs

• Provide whatever assistance is needed to achieve each goal

• Provide teaching and counseling

Goals of the Termination Phase

• Examine goals of helping relationship for attainment

• Make suggestions for future efforts if necessary

• Encourage patient to express his or her emotions about the termination

Factors that Promote Effective Communication

• Dispositional traits

• Rapport builders

Dispositional Traits

• Warmth and friendliness

• Openness and respect

• Empathy

• Honesty, authenticity, trust

• Caring

• Competence

• Genuineness

Rapport Builders

• Specific objectives

• Comfortable environment

• Privacy

• Confidentiality

• Patient versus task focus

• Utilization of nursing observations

• Optimal pacing

• Providing personal space


B.S.N., R.N. 7

Developing Conversation Skills

• Control the tone of your voice

• Be knowledgeable about the topic of conversation

• Be flexible

• Be clear and concise

• Avoid words that might have different interpretations

• Be truthful

• Keep an open mind

• Take advantage of available opportunities

Developing Listening Skills

• Sit when communicating with a patient.

• Be alert and relaxed and take your time.

• Keep the conversation as natural as possible.

• Maintain eye contact if appropriate.

• Use appropriate facial expressions and body gestures.

• Think before responding to the patient.

• Do not pretend to listen.

• Listen for themes in the patient’s comments.

• Use silence, therapeutic touch, and humor appropriately.

Interviewing Techniques

• Open-ended questions or comments

• Closed questions or comments

• Validating questions or comments

• Clarifying questions or comments

• Reflective questions or comments

• Sequencing questions or comments

• Directing questions or comments

Basic Components of Assertiveness

• Having empathy

• Describing one’s feelings or the situation

• Clarifying one’s expectations

• Anticipating consequences

Blocks to Communication

• Failure to perceive the patient as a human being

• Failure to listen

• Inappropriate comments and questions

• Using clichés

• Using closed questions

• Using questions containing the words “why” and “how”

• Using questions that probe for information

Blocks to Communication (continued)

• Using leading questions

• Using comments that give advice

• Using judgmental comments

• Changing the subject

• Giving false assurance

• Using gossip and rumors


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Type of Questions Used in Interviews

• Closed questions — elicit specific information

• Open-ended questions — allow the patient to verbalize freely

• Reflective questions — encourage patient to elaborate on thoughts and feelings

• Direct questions — validate or clarify information

Sources of Data

• Patient

• Family and significant others

• Patient record

• Other healthcare professionals

• Nursing and other healthcare literature

Problems Related to Data Collection

• Inappropriate organization of the database

• Omission of pertinent data

• Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data

• Failure to establish rapport and partnership

• Recording an interpretation of data rather than observed behavior

• Failure to update the database

When to Verify Data

• When there is a discrepancy between what the person is saying and what the nurse is observing

• When the data lack objectivity

Validating Inferences

• Performing a physical examination using proper equipment and procedure

• Using clarifying statements

• Sharing inferences with other team members

• Checking findings with research reports


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Documentation of Data

• Enter initial database into computer or record in ink on designated forms the same day patient is admitted.

• Summarize objective and subjective data in concise, comprehensive, and easily retrievable manner.

• Use good grammar and standard medical abbreviations.

• Whenever possible, use patient’s own words.

• Avoid non-specific terms subject to individual interpretation or definition.

Objective Data vs. Subjective Data

• Objective data

– Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them

– E.g., elevated temperature, skin moisture, vomiting

• Subjective data

– Information perceived only by the affected person

– E.g., pain experience, feeling dizzy, feeling anxious

Characteristics of Data

• Complete

• Factual and accurate

• Relevant

Overview of the Five Steps of the Nursing Process: DIAGNOSING

Overview of the Five Steps of the Nursing Process: DIAGNOSING

• It is a process which results to Nursing Diagnosis.

• It is used to identify health care needs and prepare a Nursing Diagnosis.

• Nursing Diagnosis is a statement of a client’s potential or actual health problem resulting from analysis of data.

• Nursing Diagnosis uses PES format:

P – roblem

E – tiology

S – igns and Symptoms

• Activities:

1. Data Clustering

2. Comparing data against standards

3. Data analysis

4. Identify gaps and inconsistencies

5. Determine health problems

6. Formulation of Nursing Diagnosis

• Types of Nursing Diagnosis:

1. Actual Nursing Diagnosis – problem is present

2. Potential Nursing Diagnosis – problem may arise

3. Possible Nursing Diagnosis – problem may be present

4. Wellness Nursing Diagnosis – transition from a specific level of wellness to a higher level of wellness

Prioritizing nursing diagnosis is based on what problem endagers person’s life.

Purposes of the Diagnosing Step

• Identify how an individual, group, or community responds to actual or potential health and life processes.

• Identify factors that contribute to or cause health problems (etiologies).

• Identify resources or strengths the individual, group or community can draw on to prevent or resolve problems.


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Nursing Concerns and Responsibilities (Alfaro, 2004)

• Monitoring for changes in health status

• Promoting safety and preventing harm

• Identifying and meeting learning needs

• Promoting comfort and managing pain

• Promoting health and well-being

• Addressing problems that limit independence

• Determining human responses

Types of Diagnoses

• Nursing diagnosis

– Describes patient problems nurses can treat independently

• Medical diagnosis

– Describes problems for which the physician directs the primary treatment

• Collaborative problems

– Managed by using physician-prescribed and nursing-prescribed interventions


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Four Steps of Data Interpretation and Analysis

• Recognizing significant data

– Comparing data to standards

• Recognizing patterns or clusters

• Identifying strengths and problems

• Reaching conclusions

Reaching Conclusions

• No problem

• Possible problem

• Actual or potential nursing diagnosis

• Clinical problem other than nursing diagnosis

Formulation of Nursing Diagnoses

• Problem — identifies what is unhealthy about patient

• Etiology — identifies factors maintaining the unhealthy state

• Defining characteristics — identifies the subjective and objective data that signal the existence of a problem

Overview of the Five Steps of the Nursing Process: PLANNING

• Identifying beforehand the specific actions to be done before implementation of nursing interventions.

• It is used to determine the goals of care and the course of actions to be undertaken during the implementation phase.

• Activities:

1. Priority setting

2. Setting goals and objectives: Goals may be short-term or long term; the characteristics of a well-started behavioral objectives are as follows:

S – mart

M – easurable

A – ttainable

R – ealistic

T – ime-framed

3. Identify alternative nursing care

4. Select nursing measure

5. Formulation of Nursing Care Plan (NCP)

The Nursing Care Plan is made mainly as guide to individualize care.

Goal of Outcome Identification and Planning Step

• Establish priorities.

• Identify and write expected patient outcomes.

• Select evidence-based nursing interventions.

• Communicate the plan of care.


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A Formal Plan of Care Allows the Nurse To:

• Individualize care that maximizes outcome achievement

• Set priorities

• Facilitate communication among nursing personnel and colleagues

• Promote continuity of high-quality, cost effective care

• Coordinate care

• Evaluate patient response

• Create a record used for evaluation, research, reimbursement and legal reasons

• Promote nurse’s professional development

Three Elements of Comprehensive Planning

• Initial

• Ongoing

• Discharge

Initial Planning

• Developed by the nurse who performs the nursing history and physical assessment

• Addresses each problem listed in the prioritized nursing diagnoses

• Identifies appropriate patient goals and related nursing care

Ongoing Planning

• Carried out by any nurse who interacts with patient

• Keeps the plan up to date

• States nursing diagnoses more clearly

• Develops new diagnoses,

• Makes outcomes more realistic and develops new outcomes as needed

• Identifies nursing interventions to accomplish patient goals


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Discharge Planning

• Carried out by the nurse who worked most closely with patient

• Begins when the patient is admitted for treatment

• Uses teaching and counseling skills effectively to ensure home-care behaviors are performed competently

Prioritizing Nursing Diagnoses

• High priority — greatest threat to patient well-being

• Medium priority — non-threatening diagnoses

• Low priority — diagnoses not specifically related to current health problem

Maslow’s Hierarchy of Human Needs

• Physiologic needs

• Safety needs

• Love and belonging needs

• Self-esteem needs

• Self-actualization needs

Long-Term vs. Short-Term Outcomes

• Long-term — requires a longer period to be achieved and may be used as discharge goals

• Short-term — may be accomplished in a specified period of time

Categories of Outcomes

• Cognitive — describes increases in patient knowledge or intellectual behaviors

• Psychomotor — describes patient’s achievement of new skills

• Affective — describes changes in patient values, beliefs, and attitudes

Parts of a Measurable Outcome

• Subject

• Verb

• Conditions

• Performance criteria

• Target time


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Common Errors in Writing Patient Outcomes

• Expressing patient outcome as nursing intervention

• Using verbs that are not observable or measurable

• Including more than one patient behavior or manifestation in short-term outcomes

• Writing vague outcomes

Types of Nursing Interventions

• Nurse-initiated — actions performed by a nurse without a physician’s order

• Physician-initiated — actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders

• Collaborative — treatments carried out by a nurse initiated by other providers

Actions Performed in Nurse-Initiated Interventions (Alfaro, 2002)

• Monitor health status

• Reduce risks

• Resolve, prevent, or manage a problem

• Facilitate independence or assist with ADLs

• Promote optimum sense of physical, psychological, and spiritual well-being

Structured Care Methodologies

• Procedure — set of how to action steps

• Standard of care — description of acceptable level of patient care

• Algorithm — set of steps used to make a decision

• Clinical practice guideline — statement outlining appropriate practice for clinical condition or procedure

Types of Institutional Plans of Care

• Kardex plans of care

• Computerized plans of care

• Case management plans of care

– Clinical pathways, care maps

• Student plans of care

• Concept map care plan

Problems Related to Outcome Identification and Planning

• Failure to involve patient

• Insufficient data collection

• Nursing diagnoses developed from inaccurate or insufficient data

• Outcomes stated too broadly

• Outcomes derived from poorly developed nursing diagnoses

• Failure to write nursing order clearly

• Nursing orders that do not solve problems

• Failure to update the plan of care


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Overview of the Five Steps of the Nursing Process: IMPLEMENTING

On-going data collection directs revision of plan of care and interventions.

Overview of the Five Steps of the Nursing Process: IMPLEMENTING

• Putting the Nursing Care Plan into action.

• It is used to carry out the NCP and meet client’s health goals.

• Requirements for implementation:

1. Therapeutic use of self (TUOS)

2. Knowledge

3. Technical skills

4. Communication skills

• Nurses implement independent (nurse-prescribed), interdependent (collaborative), and dependent (physician’s-prescribed) nursing actions.

On-going data collection directs revision of plan of care and interventions.

Advantages of Nursing Interventions Classifications

• Standardizing nomenclature

• Expanding nursing knowledge

• Developing information systems

• Teaching decision making

• Ensuring appropriate reimbursement

• Allocating nursing resources

• Communicating nursing to non-nurses

• Linking nursing content

Outcomes for “Caregiver Home Readiness”

• Willing to assume caregiver role

• Knowledge about caregiver role

• Demonstration of positive regard for care recipient

• Participation in home care decision

• Confidence in ability to manage care at home

• Knowledge of where to obtain needed equipment

Types of Nursing Interventions

• Independent nursing actions

– Nurse-initiated interventions

• Protocols

• Standing orders

• Dependent and collaborative nursing actions

– Physician-initiated interventions

– Collaborative interventions

Implementing the Care Plan

• Organize resources

• Anticipate unexpected outcomes/situations

• Promote self-care: teaching, counseling, advocacy

• Assist patients to meet health outcomes


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Aims of Teaching and Counseling

• Maintaining and promoting health

• Preventing illness

• Restoring health

• Facilitating coping

Teaching Outcomes

• High-level wellness and related self-care practices

• Disease prevention or early detection

• Quick recovery from trauma or illness

• Enhanced ability to adjust to developmental life changes

Focus of Patient Education

• Preparation for receiving care

• Preparation before discharge from health care facility

• Documentation of patient education activity

Teaching Acronym

• T – une into the patient

• E – dit patient information

• A – ct on every teaching moment

• C – larify often

• H – onor the patient as partners in the education process

Factors Affecting Patient Learning

• Age and developmental level

• Family support networks and financial resources

• Language deficits

• Literacy level

Critical Developmental Areas

• Physical maturation and abilities

• Psychosocial development

• Cognitive capacity

• Emotional maturity

• Moral and spiritual development


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Teaching Plans for Older Adults

• Allow extra time

• Plan short teaching sessions

• Accommodate for sensory deficits

• Reduce environmental distractions

Cope Model

• C – reativity

• O – ptimism

• P – lanning

• E – xpert information

Providing Culturally Competent Patient Education

• Develop an understanding of the patient’s culture.

• Work with multicultural team.

• Be aware of personal assumptions, biases, and prejudices.

• Understand the core cultural values of the patient or group.

• Develop written material in native language of the patient.

• Use testimonials of persons with same cultural background as the patient.

Three Learning Domains

• Cognitive — storing and recalling of new knowledge in the brain

• Psychomotor — learning a physical skill

• Affective — changing attitudes, values, and feelings

Key Points to Effective Communication

• Be sincere and honest.

• Avoid too much detail and stick to the basics.

• Ask for questions.

• Be a cheerleader for the patient.

• Use simple vocabulary.

• Vary the tone of voice.

• Keep content clear.

• Listen and do not interrupt.

Sources of Information

• Primary — patient

• Secondary — medical records, patient family


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Assessment Parameters

• Readiness to learn

• Ability to learn

• Learning strengths

Promoting Compliance

• Be certain that instructions are understandable and support patient goals.

• Include the patient and family as partners in process.

• Utilize interactive teaching strategies.

• Develop interpersonal relationships with patients and their families.

Sample Teaching Strategies

• Cognitive domain — lecture, panel, discovery, written materials

• Affective domain — role modeling, discussion, audiovisual materials

• Psychomotor domain — demonstration, discovery, printed materials

Teaching Strategies

• Lecture

• Discussion

• Panel discussion

• Demonstration

• Discovery

• Role playing

• Audiovisual materials

• Printed materials

• Programmed instruction

• Web-based instruction

Considerations for Successful Patient Teaching

• Forming contractual agreements

• Considering time constraints

• Scheduling

• Group versus individual teaching

• Formal versus informal teaching

• Manipulating the physical environment

Obtaining Feedback About Learning

• Reinforcing and celebrating learning

• Evaluating teaching

• Revising the plan


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Documentation of the Teaching-Learning Process

• Summary of the learning need

• The plan

• The implementation of the plan

• Evaluation results

Guidelines to Patient Counseling

• Make everyone feel comfortable in the situation and surroundings.

• Counseling may be formal or informal.

• Use interpersonal skills of warmth friendliness, openness, and empathy.

• Caring is fundamental in the counseling role.

Types of Counseling

• Short-term

• Situational crisis

• Long-term

• Developmental crisis

• Motivational

Variables Influencing Outcome Achievement

• Patient variables

– Developmental stage

– Psychosocial background

• Nurse variables

– Resources

– Current standards of care

– Research findings

– Ethical and legal guides to practice

Common Reasons for Noncompliance

• Lack of family support

• Lack of understanding about the benefits

• Low value attached to outcomes

• Adverse physical or emotional effects of treatment

• Inability to afford treatment

Factors to Consider When Delegating Nursing Care

• Patient condition

• Complexity of the action

• Potential for harm

• Degree of problem-solving and innovation necessary

• Level of interaction required with patient

• Capabilities of UAP

• Availability of professional staff to accomplish workload


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Nursing Care That Should Not Be Delegated to a UAP

• Initial and ongoing nursing assessment

• Determination of nursing diagnoses, plans, evaluations

• Supervision and education of nursing personnel

• A nursing intervention requiring professional nursing knowledge, judgment and/or skill

Five Rights of Delegation

• Right task

• Right circumstances

• Right person

• Right direction/communication

• Right supervision

Overview of the Five Steps of the Nursing Process: EVALUATING

Overview of the Five Steps of the Nursing Process: EVALUATING

• Measuring the client’s health achievements based on the goals specified.

• It is used to determine the extent of which goals of nursing care have been achieved.

• Activities:

1. Data collection about the client’s response

2. Compare data to outcome criteria

3. Analyze the result

4. Modify the Nursing Care Plan as necessary

To encourage further goal achievement, it is important for the nurse to evaluate client’s goal achievment as early as possible.

Evaluating Step

• Allows achievement of outcomes

• Directs nurse-patient interactions

• Measures patient outcome achievement

• Identifies factors to achieve outcomes

• Modifies the plan of care, if necessary

Action Based on Outcome Achievement

• Terminate plan of care

• Modify plan of care

• Continue plan of care


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Five Classic Elements of Evaluation

• Identifying evaluative criteria and standards

• Collecting data

• Interpreting and summarizing findings

• Documenting judgment

• Terminating, continuing, or modifying the plan

Evaluative Criteria vs. Standards

• Criteria — measurable qualities, attributes, or characteristics that specify skills, knowledge, or health status

– Describe acceptable levels of performance by stating expected behaviors of nurse or patient

• Standards — levels of performance accepted and expected by the nursing staff

– Established by authority, custom, or consent

Four Types of Outcomes

• Cognitive — increase in patient knowledge

• Psychomotor — patient’s achievement of new skills

• Affective — changes in patient values belief, and attitudes

• Physiologic — physical changes in the patient

Evaluating Outcomes

• Cognitive — asking patient to repeat information or apply new knowledge

• Psychomotor — asking patient to demonstrate new skill

• Affective — observing patient behavior and conversation

• Physiologic — using physical assessment skill to collect and compare data

Variables Affecting Outcome Achievement

• Patient

– E.g., a patient gives up and refuses treatment

• Nurse

– E.g., a nurse is suffering from burn-out

• Healthcare system

– E.g., inadequate staffing


B.S.N., R.N. 22

Evaluative Statements

• Decide how well outcome was met (met, partially met, or not met)

• List patient data or behaviors that support this decision

Revisions in the Plan of Care

• Delete or modify the nursing diagnosis.

• Make the outcome statement more realistic.

• Adjust time criteria in outcome statement.

• Change nursing interventions.

Four Steps Crucial to Improving Performance

• Discover a problem.

• Plan a strategy using indicators.

• Implement a change.

• Assess the change and/or plan a new strategy if outcomes are not met.

Improving Professional Performance

• Peer review

• Quality assurance programs

• Structure evaluations

• Process evaluations

• Outcome evaluations

• Quality improvement

• Nursing audit

• Concurrent and retrospective evaluations

Determining Adequacy of Evaluation Step

• Evaluate patient achievement of desired outcomes.

• Review how the process is used.

• Revise the plan of care if necessary.

• Participate in quality-assurance programs.


B.S.N., R.N. 23






Major Premises of Quality Improvement (Schroeder, 1994)

• Focus on organizational mission

• Continuous improvement

• Customer orientation

• Leadership commitment

• Empowerment

• Collaboration/crossing boundaries

• Focus on process

• Focus on data and statistical thinking

Questions to Insure a Firm Commitment to Evaluation

• What are the patient’s outcomes?

• What are nursing values?

• How can these values be formalized in standards and evaluative criteria?

• What data exist to determine whether criteria are met?

• How can these data best be collected, analyzed, and interpreted?

• To what courses of actions do the findings lead?






Nursing Skills

Four Blended Skills

• Cognitive skills — make sense of the situation and grasp what is necessary to achieve goals

• Technical skills — manipulate equipment skillfully to produce desired outcome

• Interpersonal skills — establish and maintain caring relationships that facilitate achievement of goals

• Ethical/legal skills — personal moral code and professional role responsibilities


B.S.N., R.N. 24

Cognitively Skilled Nurses

• Offer scientific rationale for patient plan of care

• Select nursing interventions most likely to yield desired outcomes

• Use critical thinking to solve problems creatively

Technically Skilled Nurses

• Use technical equipment with competence and ease to achieve goals with minimal distress to patients

• Creatively adapt equipment and technical procedures to needs of patients in diverse circumstances

Interpersonally Skilled Nurses

• Use interactions with patients and significant others and colleagues to affirm their worth

• Elicit personal strengths and abilities of patients to achieve health goals

• Provide the healthcare team with knowledge about patient goals and expectations

• Work collaborative with healthcare team as respected and credible colleagues

Ethically and Legally Skilled Nurses

• Are trusted to act in ways that advance interests of patients

• Are accountable for the practice

• Act as effective patient advocates

• Mediate ethical conflict among patient, significant others, and healthcare team

Considerations When Posed with a Thinking Challenge

• Purpose of thinking

• Adequacy of knowledge

• Potential problems

• Helpful resources

• Critique of judgment/decision

Characteristics of Interpersonal Caring

• Promotion of dignity and respect of patients

• Centrality of the caring relationship

• Mutual enrichment of both participants in the nurse-patient relationship


B.S.N., R.N. 25

Developing Ethical/Legal Skills

• Developing accountability

• Reporting incompetent, unethical, or illegal practice

Clinical Reasoning

Critical Thinking and Clinical Reasoning

• Is purposeful, informed, outcome-focused thinking

• Is driven by patient, family, and community needs

• Is based on principles of nursing process and scientific method

• Uses both intuition and logic, based on knowledge, skills, experience

• Requires strategies that make the most of human potential

• Is constantly reevaluating, self-correcting, and striving to improve

Steps in Concept Map Care Planning

• Develop a basic skeleton diagram.

• Analyze and categorize data.

• Analyze nursing diagnoses relationships.

• Identify goals, outcomes, and interventions.

• Evaluate patient’s responses.

handout nursing process

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