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The Nursing Process

*The Nursing Process is ...A systematic, rationale method of planning and providing individualized nursing care. Its purpose is to identify clients health status, actual or potential healthcare problems or needs, to establish plans to meet those needs and to deliver specific nursing interventions to meet those needs.(Kozier, 2004)

*The Nursing Process is ...The set of activities that professional nurses perform to determine the needs of the patient and make a judgment to provide the care that is needed.

*Standards of Competent PerformanceFormulates nursing diagnosis, through observation and interpretation of information.Formulates a care plan in collaboration with the client.Performs skills essential to the nursing actions to be taken.Delegates tasks to subordinatesEvaluates the effectiveness of the care planActs as the clients advocate.

* Standards of PracticeThe collection of data is systematicDerive nursing diagnosis from dataPlan nursing care including goalsPlan includes priorities and nursing approachesNursing actions provide for client participation in health promotion, maintenance, and restorationEvaluation of progress or lack of progress

*Problem-Solving & Priority SettingPriority Setting:Determine client health values & beliefsEstablish priorities from highest to lowestDetermine urgency or the problemProblem-Solving:Once problem is identified, collect dataAnalyze the data & identify an action-planImplement the plan, observing initial responsesEvaluate the results

Characteristics of the Nursing ProcessData from each phase provides input into the next phase. Client centered.An adaptation of problem solving and systems theory. Decision making is involved in every phase of the nursing processIt is interpersonal and collaborativeUniversally acceptable framework for nursing care in all types of setting. Nurses must use a variety of critical-thinking skills to carry out the nursing process

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*Steps of the Nursing ProcessAssessmentDiagnosisPlanningImplementationEvaluation

The Nursing ProcessOtten/403*

Otten/403

The Nursing Process

Assessment Phase

Assessment DataSubjective Data - The client states . . .

Objective Data - Vital signs - Physical assessments - Previous documentation

*Examples of DataTemp of 102 degreeI feel tiredWBC 24,000/mm3I need help to walkB/P 180/96My leg hurtsRedness and swelling in R ankle

ASSESSINGIs the systematic and continuous collection, organization, validation and documentation of data. Assessing is a continuous process carried out during all phases of the nursing process. All phases of the nursing process depend on the accurate and complete collection of data.Assessment vary according to their purpose, timing, time available, and client status.*

Four types of AssessmentInitial assessment Problem focused assessmentEmergency assessment Time-lapsed assessment *

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Type of AssessmentTime PerformedPurposeexampleInitial assessmentPerformed within specified time after admission to a health care agencyTo establish a complete data base for problem identification, reference and future comparisonNursing admission assessmentProblem focused Ongoing process integrated with nursing careTo determine the status of a specific problem identified in an earlier assessment.To identify new or overlooked problems- Hourly assessment of fluid intake and urinary output

-The ability to perform self-care while assisting to batheEmergency assessmentDuring any physiologic or psychologic crisis of the clientTo identify life-threatening problems- Rapid assessment of airway, breathing status and circulation (emergency)- Suicidal tendencies

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Type Time performedPurposeExample Time-lapsed assessmentSeveral months after initial assessmentTo compare the clients current status to baseline data previously obtainedReassessment of a clients functional health patterns in a home care or outpatient setting or in a hospital, at shift change

Nursing assessment focus on a clients responses to a health problem. It includes:Perceived needsHealth problemsRelated experienceHealth practices Values lifestyles*

Assessment Activities (Collecting Data)DATA COLLECTIONA process of gathering information about a clients health status. It is systematic and continuous (to prevent ommission of significant data and reflect a clients changing health status. DATA BASE is all information about the client, includes the nursing history, physical examination, physicians history & PE, results of laboratory and diagnostic tests material contributed by other health personnelNursing Health History (263)Functional Health Patterns (Gordon)*

Types of Data Subjective data Symptoms or covert data Apparent only to the person affected and can be described or verified by him aloneSensation, feelings, values, beliefs, attitudes, perception of personal health status and life situation Objective dataSign or overt dataDetectable by the observer or can be measured or tested against an accepted standard.Seen, hear, felt, or smelledObtained by observation or PE

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Sources of DataPrimary source Client the best source of data, unless too ill, young or confused to communicateSecondary sourceSupport people (significant others SO)Client recordsHealth care professionals Literature *

Data Collection MethodsOBSERVINGUse of the senses Vision, smell, hearing, touch Has two aspects:Noticing the dataSelecting, organizing and interpreting the data*

INTERVIEWINGInterview is a planned communication or a conversation with a purpose (to get/ give information), to identify problems of mutual concern, evaluate change, teach, provide support, or provide counseling or therapy. Nursing health history *

Two approaches to interviewing:Directive interview Highly structured and elicits specific informationNurse establishes the purpose and controls the interviewClient responds but with limited opportunity to ask questions and discuss concernsFrequently used to gather and give information when time is limitedNondirective interviewOr rapport- building interview (rapport is understanding between two people)Client control the purpose, matter and pacingA combination of the two is important during information-gathering interview.*

INTERVIEW QUESTIONSClosed questions in directive interview Restrictive require only yes, no, short factual answersBegin with when, where, who, what, do (did, does), is (are, was) are you in pain, how old are you*

Open-ended questions Nondirective interviewInvite clients to discover and explore, elaborate, clarify or illustrate their thoughts or feelingsSpecifies only broad topic to be discussed. Begin with how or what what brought you to he clinic?, how are you feeling today?*

Neutral question Client can answer without direction or pressure from the nurseOpen-ended, used in nondirective interviewHow do you feel about that?Leading question Usually closed, used in directive interview.youre stressed about surgery tomorrow, arent you? *

PLANNING THE INTERVIEW AND SETTINGBEFORE beginning, review available information (clients chart), review agencys data collection form, make an interview guideThe following influence the interview:TimePlaceSeating arrangement Distance Language *

TIME Physically comfortableFree of painInterruptions are minimalMake the client feel comfortable and unhurried*

PLACEWell-lighted, well-ventilated, moderate-sized roomFree of noise, movement and interruptionsEncourage communicationsOthers cannot hear or see (privacy)SEATING ARRANGEMENTEqual terms parties sit in two chairs at right angle to a desk or table, few feet apart, with no table betweenCreates less formal atmosphere If standing or looking down if client on bed, makes intimidating, nurse can sit 45 degree angle to bed*

DISTANCE Between the interviewer & interviewee should neither be too small nor too great, because people feel uncomfortable when talking to someone who is too close or too far.Maintaining a distance of 2-3 feet Some clients require a more or less personal space depending on their cultural and personal needs. *

ACCEPTED distance in conversation varies with ethnicity8-12 in Arab18 in in US24 in in Britain36 in in JapanMen require more spaceAnxiety needs more spaceDirect eye contact increases the need for spacePhysical contact is used only for therapeutic purpose (TOUCH)*

LANGUAGEFailure to communicate in language the client can understand is a form of discrimination. Convert complicated medical terminology into common English or language for the client. *

STAGES OF INTERVIEWTHE OPENINGMost important part, what is said and done sets the tone for the remainder of the interview.Establish rapportOrientation THE BODYThe client communicates what she thinks, feels, knows and perceives in response to nurses questionsTHE CLOSINGNurse terminates or ends the interviewClients may also terminate it (page 268)

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EXAMINING Physical assessment or physical examination A systematic collection of data that uses observation to detect health problemsI-P-P-A approach can be used. Head-to-toe, body systems approach the nurse may also focus on a specific problem identifiedScreening examination or Review of Systems is a brief review of essential functioning of various body parts, compared against standard

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ORGANIZING THE DATASchools of nursing have developed their own based on selected theories:Gordons 11 functional health patternsOrems self-care modelRoys adaptation model *

VALIDATING THE DATAValidation is the act of double-checking or verifying the data to confirm that it is accurate and factual. Ensure assessment is completeEnsure subjective and objective data agreeDifferentiate cue from inference Avoid jumping to conclusions and focusing in the wrong directionNot all data require validation To collect data accurately, nurses need to be aware of their own biases, values and beliefs and separate fact from inference, interpretation and assumption. *

DOCUMENTING THE DATATo complete the assessment phase, the nurse records client dataRecord subjective data in clients own words. *

Diagnosis Phase

*A Nursing Diagnosis is ...A description of the clients response to a disease state, process, condition or situation. It is a clinical judgment about an individual, family or community responses to actual/potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve desired client outcomes.(NANDA, 1990)

*Comparing Nursing & Medical DiagnosesNursing Diagnosis Describes a response to a disease process, condition or situation Oriented to individual changes as client changes

Compliments medical diagnoses

Teaches client re self-careMedical Diagnosis Describes a specific disease process

Oriented to pathology & remains constant Well defined classification systemTeaches clients about treatments

*Advantages & Disadvantages of Nursing DiagnosesAdvantages:Provides a common language for nursesOutcome-orientedEfficient, Organized , Systematic, and Goal DirectedDisadvantages:Inconsistently usedNot always formally recognized (by MDs.)Some problems dont fit diagnostic statements as outlined by NANDA

*Two Types of Nursing DiagnosesActual Problems:Altered Nutrition, less than body requirements related to poor oral intake as evidenced by weight loss of 12 lbs. in two weeks.Potential Problems:High risk for infection (Potential for) related to decreased primary defenses.

*Components of a Nursing DiagnosisActual Problem (3 Part Statement)Diagnostic Label/Statement (Problem Statement): Activity Intolerance Impaired Physical Mobility (identifies unhealthy responses, what needs change)Etiology (Contributing Factors) related to _______________ (identifies factors causing undesirable response)Defining Characteristics (Manifestations) as evidenced by __________ (what you see)

*Components of a Nursing DiagnosisPotential Problems (2 Part Statement)Diagnostic Label/StatementEtiology (Contributing Factors)

Analyzing the DataCompare data against the standards. Cluster the cues Identify gaps and inconsistencies *

Compare data against standards:Standard or norm is a generally accepted measure, rule, model or pattern. Example: growth and development patterns, normal vital signs, laboratory values. Cue is significant if:Points to negative or positive change in a clients health status or pattern. Varies from norms of the client population Indicates a developmental delay

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Clustering cues:Determine the relatedness of facts and determining whether any patterns is present. The nurse may cluster data inductively, or use a framework, or deductively. Data clustering involves making inferences about the data, interpret the meaning by making tentative diagnostic hypotheses (Table 17-5) *

Example: Using the functional health pattern *

FUNCTIONAL HEALTH PATTERNCLIENT CUE CLUSTERSINFERENCESDIAGNOSTIC STATEMENTS ACTIVITY / EXERCISEDifficulty sleeping because of cough

Cant breathe lying downDisturbed sleep patternDisturbed sleep pattern related to cough, pain, orthopnea. COGNITIVE/ PERCEPTUALReports pain in the chest especially when coughingAcute painAcute pain (chest) R/T cough secondary to pneumonia

Identify Gaps and Inconsistencies:Can be avoided if nurse had a good assessmentInconsistencies are conflicting data *

Gordons 11 Functional Health Patterns Assessment Questions1.Health Perception-Health Management Pattern.In general, how is the familys health? What do you do to stay healthy?Do you drink alcohol or use tobacco products? Do you haveregular check-ups with your physician and/or specialists (Pediatrician, Ob/Gyn, Cardiologist, etc.)? Do you listen to and follow any suggestions made by your health care providers?2.

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2. Nutritional-Metabolic Pattern.Describe your Familys typical daily food intake? Do you consider your family healthy eaters?.Describe your familys typical daily fluid intake? Do you drinkalcohol? .Does anyone consider themselves over or under weight?Is there any unexplained weight gain or loss?

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Avoiding errors in diagnostic reasoningVerify Build a good knowledge base and acquire clinical experience Have a working knowledge of what is normalConsult resources Base diagnoses on patterns on behavior over time rather than on an isolated incident Improve critical thinking skills. *

NCP format *

CUES

NURSING DIAGNOSIS

RATIONALE TO NURSING DIAGNOSISSubjectiveObjectiveNANDA [P-E-S / P-E] Explain the reason for the nursing diagnosis chosen

Planning Phase

PLANNING Is a deliberative, systematic phase of the nursing process that involves decision making and problem solving Refer to the clients assessment data and diagnostic statement *

NURSING INTERVENTIONany treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/ client outcomes. (McCloskey & Bulecheck)Product is a client care plan Nurses plan WITH the client. Encourage the clients to participate. *

TYPES OF PLANNINGInitial planning From the first client contact until nurse-client relationship ends (discharge). Ongoing planning Done by nurses who work with the client, as nurses obtain new information (individualize) To determine if status has changes, set priorities for care during the shift, decide which problem to focus during the shift, coordinate nurses activities, so more than one can be addressed at each client contactDischarge planning Process of anticipating and planning for needs after dischargeBegins at first client contact

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Informal nursing care planA strategy for action that exists in the nurses mindFormal nursing care plan A written or computerized guide that organizes information about the clients careStandardized care planA formal plan that specifies the nursing care for groups of client with common needs (hypertension)Individualized care planIs tailored to meet the unique needs of a specific client*

Nurses use formal care plan for direction about what needs to be documented in clients progress notes and as a guide for delegating and assigning staff to care for clientsWhen nurses use the NURSING DIAGNOSES to develop goals and nursing interventions, the result is a holistic, individualized plan of care that will meet the clients unique needs*

Care plans include actions nurses must take to address the clients nursing diagnoses and produce the desired outcomesBEGIN upon admission to agencyConstantly updates it throughout the clients stay - in response to changes in clients condition and evaluations of goal achievement*

During the planning phase:Nurse decide which client need individualized plans, standardized plans and routine careWrite individualized desired outcomes and nursing orders for client problems that require nursing attention beyond preplanned routine care*

Complete plan of care:A. Routine care needed to meet basic needsB. Address the clients nursing diagnoses and collaborative problems C. Specify the medical responsibilities in carrying out the plan of care

Complete plan of care integrates dependent and independent nursing functions into a meaningful whole *

STANDING ORDER A written document about policies, rules, regulations, or orders regarding client care .Gives nurses the authority to carry out specific actions under certain circumstances , often when a physician is not immediately available *

Concept MapPage 312 (Ineffective airway clearance) It is a visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationships between these are indicated by connecting lines or arrows *

Multidisciplinary (Collaborative CP)Standardized plan that outlines the care required for clients with common, predictable usually medical conditionsAlso called critical pathways sequence the care that must be given on each day during the projected length of stay for the specific type of condition*

Guidelines for Writing NCP1. date and sign the plan for evaluation, review, future planning/ signature demonstrates accountability 2. use category heading (Cues/ Nursing Diagnosis) include date for evaluation of each goal3. use standardized medical or English symbols and key words rather than complete sentences to communicate your ideas4. be specific (every shift broad) *

5. refer to procedure books rather than including all steps on a written plan6. tailor the plan to the unique characteristics of the clients by ensuring that the clients choices such as preferences about the times of care and methods used are included7. ensure that NCP incorporates preventive and health maintenance aspects as well as restorative ones8. ensure that the plan contains interventions for ongoing assessment *

9. include collaborative and coordination activities in the plan 10. Include plans for clients discharge and home care needs. *

Planning ProcessSetting prioritiesEstablishing client goals/ desired outcomesSelecting nursing interventions Writing nursing orders*

1. SETTING OF PRIORITIESPriority setting is the process of establishing a preferential sequence for addressing nursing diagnosis and interventions (together with the client)High, Medium, Low priority Life-threatening problem high priorityHealth threatening medium priority ( acute illness, decreased coping)Arises from normal developmental needs/ or requires minimal nursing support low priority

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Nurses frequently use Maslows Hierarchy of needs in prioritizingNot necessary to resolve all high-priority before addressing the other problems Priorities change as clients responses, problems, and therapies change *

Factors to consider when prioritizing1. Clients health values and beliefs .. Resolve if conflicting with nurse, but in life-threatening situation, the nurse take the initiative2. Clients priorities . . . If conflicting, resolve and knowledge of the nurse more important3. Resources available to the nurse and client 4. Urgency of the health problem5. Medical treatment plan *

*Planning Phase: Goals & OutcomesGoals are broad statements about the effects of nursing interventions on the client (overall, non-measurable statements) Outcomes are specific, measurable criteria used to evaluate whether goals have been met based on specific nursing interventions

*Outcome Statements (Criteria)Outcomes are derived from the diagnosisOutcomes are measurable/behavioralOutcomes are realistic compared to the clients self-care abilitiesOutcomes have a time-frame for completionOutcomes provide direction for care

*Planning Phase: InterventionsInterventions should be developed which are consistent with the established plan of care

Interventions should be implemented in a safe, appropriate manner based on sound nursing theory and judgment

*Planning Phase: InterventionsInterventions should always be documented in the medical recordInterventions should be realistic for client, based on abilities and resources

*Types of Nursing InterventionsIndependent: Able to be implemented without a physicians order

Dependent: Must have or obtain physicians order to implement this intervention

Collaborative: Combination of dependent/independent nursing intervention

*Types of Nursing FunctionsIndependent: functions that are within scope of nursing practice.Assessment - history and physicalNursing diagnosis, which require nursing interventionsNursing actionsReferrals to other health membersEvaluation of patients responses

*Types of Nursing FunctionsInterdependent: activities that are carried out in conjunction with other health team members.RN works with a dietician to help a diabetic patient control blood sugar.RN works with PT to help improve patients ambulation.

*Nursing FunctionsDependent: activities performed based on the physicians ordersAdministration of medicationCarrying out specific treatments

*Independent? Interdependent? Dependent?Patient has a B/P of 160/100, the RNRetakes the B/P; ask the pt what he was doing.Asks the pt. how he is feeling, notes changesChecks B/P with the previous B/P readings.Checks the MDs order for any related orders.Gives treatments ordered by the MD.Monitors effects of medication.Teaches the pt. relaxation techniques.

*Focus of Patient CareMedicine and NursingPatient reports, It feels like my chest is being crushedObservations show facial grimace, SOB (shortness of breath), and diaphoresis (perspiring)

*Focus of Patient CareGoal of Medicine: cure, treat disease, heal physiologic beingGoal of Nursing: works with the whole person

*Focus of Patient CareMedical interpretation of pain: diminished blood flow from coronary arteries to myocardiumProbable Diagnosis: Myocardial InfarctionNursing interpretation: Pain in the chestProbable Nursing Diagnosis: chest pain related to cardiac disease

*Focus of Patient CareMedical Plan: dependent functionsBedrestVital Signs q 15 min.Morphine 2mg IV prnNTG 1/200 gr SL prnEKG, O2 at 2L/min

Nursing Plan: independent functionsMonitor EKG and dysrhythmiaAssess chest painEmploy comfort measures, allow restAlleviate anxiety

NURSING ORDERS Instructions for the specific individualized activities the nurse performs to help the client meet established health care goals. Components:Date Action verbContent area Time elementSignature Observation orders, prevention orders, treatment orders and health promotion orders

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Implementation Phase

ImplementingConsists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions or nursing orders. Nurses performs or delegates, then finally records the activities & resulting client responsesThe nurse may act on the clients behalf, but professional standards support client & family participation in all phases of the nursing processThe aim: to make the client independent*

*Implementation Skills (3)Require cognitive skills (intellectual skills)Require interpersonal skillsRequire technical skills

COGNITIVE SKILLSInclude:Problem solvingDecision making Critical thinking Creativity These are crucial to SAFE, INTELLIGENT nursing care

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INTERPERSONAL SKILLSALL of the activities verbal & nonverbal, people use when interacting directly with one another. Effectiveness of nurses action depends largely on the nurses ability to communicate with others.Nurses use therapeutic communication to understand the client and in turn be understood.A nurse also needs to work effectively with others as a member of the health team *

Interpersonal skills are necessary for all nursing activities:Caring Comforting Advocating Referring Counseling Supporting *

Interpersonal skills also include:Conveying knowledge, attitudes, feelings, interest, and appreciation of the clients cultural values and lifestyle.

Before nurses can be highly skilled in interpersonal relations they must have SELF AWARENESS and SENSITIVITY to others *

TECHNICAL SKILLSHands-on skills such as:Manipulating equipment, giving injections and bandaging, moving, lifting, and repositioning clients. also called:Tasks, procedures, psychomotor skills Psychomotor skills includes interpersonal component (like when you communicate with the client) *

Reassessing the ClientJust before implementing the intervention - Re-assess to make sure the intervention is still neededdisturbed sleep pattern related to anxiety & unfamiliar surroundings *

Determining the clients need for assistance Reasons:The nurse is unable to implement the nursing activity safely aloneAssistance would reduce stress on the client The nurse lacks the knowledge or skills to implement a particular nursing activity *

Guidelines when implementing nursing actions Explain to the client what interventions will be done, what sensations to expect, what the client is expected to do, and what the expected outcome is. Ensure clients privacy Coordinate your care scheduling contacts with other departments and serving as liaison *

Base nursing actions on scientific knowledge, nursing research and professional standards of care (evidence-based practice) Aware of the scientific rationale, side effects, complications Clearly understand the orders to be implemented and question any that are not understood. The nurse is responsible for intelligent implementation of the care plan. This requires knowledge of each intervention, its purpose in the clients plan of care, any contraindications and changes in the clients condition that may affect the order. *

Adapt activities to the individual client.A clients beliefs, values, age, health status and environment are factors that can affect the success of nursing actions.Implement safe careObserve sterile technique, administer the correct dosageProvide teaching, support and comfortIndependent nursing activities enhance effectiveness of nursing care planBe holisticAlways view the client as a whole*

Respect the dignity of the client and enhance their self-esteemProvide privacy, encourage to make their own decisionsEncourage clients to participate actively in implementing the nursing interventions Active participation enhances their sense of independence and control.However, degree of involvement is related:To the severity of the illnessCulture FearUnderstanding of the illness and intervention

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Supervising delegated care Nurses ensure that care delegated is according to the care plan. Others communicate their activities to the nurse by documenting them on the client record, report verbally, or fill out the written form*

Documenting nursing activitiesThe nurse completes the implementing phase by recording the interventions and client responses in the nursing progress notes Nursing care must not be recorded in advance Nurse may record routine or recurring activities in the client record at the end of the shift. In some cases it should be recorded immediately (like medications & treatment for safety )Nursing activities are communicated verbally and in writing Nursing activities are also recorded at the change of shift

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Evaluation Phase

The Nursing ProcessSTEP 5Evaluation determining the clients progress

monitoring the clients response

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Evaluating To judge or to appraise A planned, ongoing, purposeful activity in which clients and health care professionals determine:clients progress toward achievements of goals/outcomesThe effectiveness of the NCP

Important part because conclusions drawn from the evaluation determine whether nursing interventions should be terminated, continued or changed*

Evaluation is continuous Done immediately after implementation At a specified intervalIt is continued until the client achieves the health goals or discharged from nursing careAt discharge includes the status of goal achievement Through evaluating, nurses demonstrate responsibility and accountability for their actionsSuccessful evaluation depends on the effectiveness of the steps that precede it. *

Process of evaluating client responseBefore evaluation, the nurse identifies the desired outcomes that will be used to measure the client goal achievement. (PLANNING step) Two purposes of desired outcomes:They establish the kind of evaluation data that need to be collected They provide a standard against which the data are judged *

5 components of the evaluation processCollecting data related to the desired outcomesComparing the data with outcomesRelating nursing activities to outcomesDrawing conclusions about problem status Continuing, modifying, or terminating nursing care plan *

*Evaluation ProcessCompare the actual to expected outcomes - Did my client achieve their outcomes?- If not, determine why outcomes were unmet - Were the outcomes realistic? Correct problem? Enough time to achieve outcomes?If you determine the outcomes to be appropriate, assess the interventions -Were the interventions appropriate? Were they completed? Does the client require other nursing interventions?If everything looks good, continue with plan of care, observing for improvement

Collect dataUse the clearly stated, precise, measurable desired outcomes both objective & subjective dataCompare data with outcomesBoth the nurse and client do this Three possible conclusions:The goal was met: clients response the same as the desired outcome Goal partially met: either a short term goal was met, but long term goal not, or desired outcome only partially metGoal was not met example: Goal met: Oral intake 300 ml more than output, skin turgor is good, mucous membrane moist*

Evaluation checklist tabel 19-1: page 322*

*Purposes of a Written Care PlanProvides direction & individualizes client careProvides for continuity of careProvides direction for follow-up & documentationProvides assistance in assigning staffProvides information for reimbursement

*Mrs. Ida Hubert, 67 y.o.Admitted to the unit with diagnosis of lung cancer with bone metastases 3 days agoMeds: morphine 180 mg daily; Tylenol 650 mg +Oxycodone 10 mg q6h p.r.n.Morning report: Mrs. Huber had been restless all night

*What assessments would you want to make in your preparation for her care?Chart review: Has been taking narcotics for 2 months; spends most of her days in bed

*Assessment of Mrs. HubertPatient interview: Alert and responsiveCouldnt sleep or rest; just couldnt get into a comfortable position. Had trouble describing her discomfort. Reported decreased appetite, ate 3 small meals/day, one 8 oz can of supplement. Said she is drinking very little fluids

*Assessment of Mrs. HubertMeasurements:V.S. were stableHad active bowel sounds, abdomen non-tender to palpation, but noted a firm area in LLQ.Said she had not had a BM since admission (3 days ago).What nursing diagnosis might be appropriate for Mrs. Hubert?

*Critical Thinking: What is it?Critical thinking is making decisions based on reason, reflection, knowledge and instinct derived from experience. Critical thinking helps nurses make patient-care decisions by helping them to think creatively, and explore new ideas and alternative ways of solving problems.(Catalano, 1996)

*The Critical Thinking ProcessIdentify the problemIdentifying the underlying beliefs (patient, personal and other healthcare providers)Find support for the beliefs (accurate, timely, consistent literature/research)Evaluate the situation for possible solutions and weigh the solutions against the beliefs and valuesPresent a course of action

Comparison of SOAP & Nursing Process StepsSubjectiveObjectiveAssessmentPlanAssessmentDiagnosisPlanImplementationEvaluation