[ppt]care plan/concept map workshop - mercer ... · web viewnrs 110 now lets write the plan down!...
TRANSCRIPT
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CLINICAL DECISION MAKING & THE NURSING PROCESSNRS 110
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Critical Thinking Revisited
• Knowledge
• Experience
• Reflection
• Intuition
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Components of Critical Thinking in Nursing
• Specific Knowledge Base• Experience• Critical Thinking Competencies• Diagnostic Reasoning• Clinical Decision Making• Nursing Process• Critical Thinking Attitudes• Critical Thinking Standards• Intellectual Standards• Professional Standards
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Clinical Decision Making
• Critical thinking process for choosing the best actions to meet a desired goal
• To act or not to act, that is the question!• Criteria used to make decisions• Collaboration• Problem Identification• Who is responsible for making the
decision?
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Level of Critical Thinking
• Basic
• Complex
• Commitment
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NURSING PROCESS
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
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The nursing process in action
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Step One: Assessment
• Collect data (Types of data, Sources of data, Methods of data collection)
• Organize data
• Validate the data
• Record & report
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Step 2: Diagnosis
• Analysis of assessment data leads to problem identification
• NANDA list• Types of nursing dx.
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Anatomy of a Nursing Diagnosis
• Problem (Diagnostic label)• Etiology (Related factors and Risk
factors)• Defining Characteristics• Differentiating Nursing Diagnoses from
Medical Diagnoses• Differentiating Nursing Diagnoses from
Collaborative Problems
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The Diagnostic Process
• Analyzing data: Compare data against standards, cluster data, identify gaps and inconsistencies in data
• Identify health problems, determine problems and risks, determine strengths
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Formulating Diagnostic Statements
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Step 3: Planning
• Set priorities• Apply standards• Identify goals &
outcomes• Select interventions• Record the plan
(nursing care plan)
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What are the priorities?
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Maslow’s Hierarchy of Basic Human Needs
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Guidelines for Writing Goal Statements
• Write goals in terms of client responses• Be sure the desired outcomes are
realistic and compatible with ordered therapies
• Make sure that each goal is derived from only one nursing diagnosis
• Use observable, measurable terms for outcomes
• Involve the client in the process
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CONCEPT MAP Ineffective Airway Clearance (Gas Exchange)
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Step 4: Implementation
• Put your plan into action
• Perform the interventions
• Note patient response to interventions
• Record & report
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Types of Interventions
• Independent (nurse initiated)• Dependent (physician initiated)• Collaborative
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Step 5: Evaluation
• Did the plan work?• Was goal achieved?• What was the
outcome of the care provided.
• Stated in measurable terms.
• It’s all about outcomes!
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Case Scenario
• A.A. is an 28 y.o. female who was admitted with pneumonia. She presents with complaint of cold x 2 weeks, dyspnea on exertion, , orthopnea, decreased oral intake. Assessment of patient reveals:
• T 103F, P 92, R 22 shallow, BP 122/80• Dry mucous membranes, hot pale skin• Decreased breath sounds, inspiratory crackles• Ineffective cough-coughing up thick pink
sputum• Lethargic, c/o being weak
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Now lets write the plan down!
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Concept Map Steps
• Place your main issue/problem in the middle• Determine key problems/concepts that have a
direct relationship to the main problem• Add clinical data to appropriate problem boxes• Draw lines between related problems. Label
with a nursing diagnosis• Identify goals/outcomes• Add interventions• Evaluate patient response to interventions
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CONCEPT MAP Ineffective Airway Clearance (Gas Exchange)