Basic Clinical Nursing Skills

Nursing Process and Critical Thinking

Nursing Process:
Definition: Nursing Process is a tool or method for organizing and delivering care or a deliberate intellectual activity where by the practice of nursing is approached in an orderly systematic manner. It is a systematic problem solving approach to client care. It is a series of planned steps and actions directed toward meeting the need and solving problems of people and their significant others; it is systematic, scientific problem solving in action (Sorensen and Luckman, 1986)

Purpose of Nursing Process: 1. To identify clients health care needs 2. To establish nursing care plan so as to meet those needs 3. To complete the nursing intervention designed to meet the needs 4. To provide individualized care

Linda Hall first introduces the term nursing process in 1965.

Step of the Nursing Process
The nursing process has five steps:
1. Assessment – the systematic collection of data to determine the patient’s health status and to identify any actual or potential health problems. In nursing assessment the best sources of information about the client are the client and the family. Health professionals, previous client records and significant others also act as information sources. Data collected about a client generally fall into one of the two categories: objective or subjective
Objective data include all the measurable and observable pieces of information about the client and his or her overall state of health. The term objective means that only precise, accurate measurements or clear descriptions are used.
Subjective data consists the client’s opinions, feelings about what is happening. Only the client can tell you that he/she is afraid or has pain. Some times the client can communicate through body language: gesture, facial expressions and body posture. To obtain subjective data you need sharp interviewing, listening, and observation skills.

Methods of data collection
Observation is an assessment tool that relies on the use of the five senses (sight, touch, hearing, smell and taste) to discover information about client.
Health interview- the health interview is a way of soliciting information from the client. This interview may also be called a nursing history.

Physical examination
(Analysis of data is included as part of the assessment. For those who wish to emphasize its importance analysis may be identified as a separate step of the nursing process.)

2. Diagnosis – identification of the following two types of patient problems:
a) Nursing diagnosis – actual or potential health problems that can be managed by independent nursing interventions.

Purposes of the Nursing Diagnosis- the nursing diagnosis serves the following purposes:
• Identifies nursing priorities • Directs nursing interventions to meet the client’s high priority needs • Provides a common language and forms a basis for communication and understanding between nursing professionals and health care team. • Guides the formulation of expected outcomes for quality assurance requirements of third party payer. • Provides a basis for evaluation to determine if nursing care was beneficial to the client and cost effective. • Is of help when making staff assignment.

The diagnostic statement
The client may present with more than one problem. Therefore, the nursing diagnosis may be made up of multiple diagnostic statements. Each diagnostic statement has two or three parts depending on the healthcare facility. The three-part statement consists of the following components: • Problem • Etiology • Signs and symptoms, a two-part diagnostic statement consists of the problem, and signs and symptoms.

The problem portion of a statement describes- clearly and concisely- a health problem a client is having. Use one of the NANDA- approved nursing diagnostic labels to state the problem
The etiology part of the diagnostic statement is the cause the problem. Etiology may be physiologic, psychological, sociologic, spiritual, or environmental.

Sign and symptoms- the third part of the diagnostic statement summarizes data. You may need to include several signs and symptoms. For instance, the client with pneumonia had cough with thick sputum, abnormal breath sounds, increased respiration, and difficulty breathing.

Writing the Diagnostic Statement
The diagnostic statement connects problem, etiology, and signs and symptoms. The first two parts of the statement are linked by” related to,” some times abbreviated R/T. The last two parts are linked by “as evidenced by,” some times abbreviated AEB.
E.G. Ineffective Airway Clearance related to physiologic effects of pneumonia as evidenced by increased sputum, coughing, abnormal breath sounds, tachypnea, and dyspnea.
b) Collaborative problems – certain physiologic complications that nurse monitor to detect onset or changes in status. Nurses manage collaborative problems using physician – prescribed and nursing prescribed interventions to minimize the complications of the events.

3. Planning – development of goals and a plan of care designed to assist the patient in resolving the diagnosed problems. Setting priorities, establishing expected outcomes, and selecting nursing interventions result in plan of nursing care.

Setting priorities
Nursing diagnoses are ranked in order of importance. Survival needs or imminent life threatening situations takes the highest priority. For example, the needs for air, water and food are survival needs. Nursing diagnostic categories that reflect these high- priorities needs include Ineffective Airway Clearance and deficient fluid volume.

Establishing Expected Outcomes
An expected outcome is a measurable client behavior that indicates whether the person has achieved the expected benefit of nursing care. It may also be called a goal or objective. An expected outcome has the following characters tics: • Client oriented • Specific • Reasonable • Measurable Selecting Nursing Intervention Nursing intervention is also called nursing orders or nursing actions, are activities that will most likely produce the desired outcomes (short-term or long-term). To achieve this outcome, one should select nursing interventions such as the following examples: • Offering fluids frequently • Positioning frequently • Teaching deep breathing exercise • Monitoring vital signs • Administering oxygen, etc. accordingly.

4. Implementation – actualization of the plan of care through nursing interventions.

5. Evaluation – determination of the patient’s responses to the nursing intervention and the extent to which the goals have been achieved.

N.B. Dividing the nursing process into five distinct components or steps serves to emphasize the essential nursing actions that must be taken to resolve patient’s nursing diagnoses and manage any collaborative problems or complications.

Critical thinking: It is defined as an intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and or evaluating information gathered from, or generated by observation, experience, reflection, reasoning or communication, as a guide to belief and action. Critical thinking involves problem solving and decision making process, but it is a more complex process. Critical thinking competencies are the cognitive processes a nurse in clinical situations include diagnostic reasoning clinical inferences, and clinical decision-making. The nurse process is considered the specific critical thinking competency in nursing. Critical thinking skill assists the nurse to look at all aspects of a situation and then at a conclusion. When critical thinking is employed in clinical situations one should expect the how to examine ideas, beliefs, principles, assumptions, conclusions, statements and inferences before coming to a conclusion and make a decision

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