Chapter 4 Theoretical Foundations of Nursing Practice Nursing

Chapter 4 Theoretical Foundations of Nursing Practice

Nursing Domain • What is a domain? • In science a domain is the view or perspective of a discipline. • Nursing’s domain • Identification and treatment of client’s health care needs at all levels of health and in all health care settings.

Nursing Domain • Person • Recipient of nursing care • Health • Defined in different ways by client • Environment/setting • In which health care needs occur • Nursing • Creates individualized plan of care

Nursing’s Paradigm (Model)

Types of Theories • Grand midrange theories • Broad in scope • Middle-range theories • Have a more limited scope; address specific concepts

Interdisciplinary Theories • Systems theory • Basic human needs • Maslow’s hierarchy of human needs • • Health-and-wellness model Stress and adaptation Developmental theories Psychosocial theories

Maslow's hierarchy of needs •

Selected Nursing Theories • Nightingale’s theory • Focus on the client’s environment • Henderson’s theory • Focus on 14 basic needs

Selected Nursing Theories (cont’d) • Orem’s theory • Focus on self-care needs • Leininger’s theory • Focus on cultural care

Nursing Process • Steps • • • Assessment Nursing diagnosis Planning Implementation Evaluation

Nursing Process

Nursing Process (cont'd) • Assessment • Critical thinking approach • When gathering data the nurse synthesizes relevant knowledge, clinical experience, critical thinking standards and attitudes and standards of practice simultaneously • Directs assessment in meaningful and purposeful way

Nursing Process (cont'd) • A critical thinker is: • proactive: anticipates problems, not reactive • systematic: gathers information, weighs it, draws conclusions • logical: bases conclusions on evidence • persistent: finishes the job • realistic: settles for a workable solution, not the ideal solution

Critical Thinking and the Nursing Process

Critical Thinking in Nursing Practice Chapter 15

Critical Thinking • An active, organized, cognitive process used to carefully examine one’s thinking and the thinking of others • A critical thinker identifies and challenges assumptions, considers what is important in a situation, imagines and explores alternatives, considers ethical principles, applies reason and logic, and thus makes informed decisions

Aspects of Critical Thinking • Reflection • Purposefully thinking back (recalling) a situation to discover its meaning • Language • Use language precisely and clearly; framing of one’s thoughts so message is clear • Intuition • Direct understanding of a situation w/out conscience deliberation

Levels of Critical Thinking • Basic critical thinking • A learner trusts that experts to have the right answers for every problem • Complex critical thinking • Begins to detach from authorities, analyze and examine alternatives more independently • Commitment • Nurse anticipates the need to make choices w/out assistance from others and then assumes accountability for those choices

Critical Thinking Competencies • Scientific method • Seeking the truth or verifying that a set of facts agrees with reality; research • Problem solving • Also involves evaluation (follow-up) • Decision making • End point in critical thinking, leads to problem resolution

Critical Thinking Competencies • Diagnostic reasoning and inference • Diagnostic reasoning- process of determining a client’s health status after the nurse assigns meaning to behaviors, physical s/s • Forming nursing diagnosis • Inference-drawing of conclusions from related pieces of evidence

Critical Thinking Competencies • Clinical decision making • Process requires careful reasoning so that the options for the best client outcomes are chosen on the basis of client’s condition and priority of problem • Criteria to aid in making appropriate choices • What needs to be achieved? • What needs to be preserved? • What needs to be avoided?

Nursing Process • • • Assessment Diagnosis Planning Implementation Evaluation

Nursing Process • Blueprint for care • Provides a creative, organized framework for delivery of nursing care • Can be used in all settings; flexible

Nursing Process

Critical Thinking • Components • • • Knowledge base Experience Competence Attitudes Standards

Critical Thinking Level 3 - Commitment Level 2 Complex Level 1 Basic Specific Knowledge Base Experience Competencies Attitudes Standards

Attitudes • Confidence • Thinking independently • Fairness • Responsibility and accountability • Risk taking • Discipline • • • Perseverance Creativity Curiosity Integrity Humility

Standards • Intellectual • Professional

Intellectual Standards • • Clear Precise Specific Accurate Relevant Plausible Consistent • • Logical Deep Broad Complete Significant Adequate (purpose) Fair

Professional Standards • Ethical criteria for nursing judgment • Criteria for evaluation • Professional responsibility

Synthesis: Critical Thinking with Nursing Process Competency

Nursing Assessment Chapter 16

Assessment - Steps • Collection and verification of data • Analysis of data

Assessment - Approaches • Use of a structured database format • Gordon’s 11 Functional Health Patterns • Pattern of health perception and health management • Nutritional/metabolic pattern • Pattern of elimination • Pattern of exercise and activity

Assessment - Approaches • • Cognitive/Perceptional pattern Pattern of sleep and rest Pattern of self-reflection and self concept Relationship pattern Role-Sexuality-Reproductive pattern Pattern of coping and stress tolerance Pattern of values and beliefs • Represents the interaction of the client & the environment

Assessment - Approaches • Problem oriented • Focuses on client's presenting problem then spread out to other relevant area’s of client’s life

Assessment – Data Collection • Types of data • Objective • Subjective • Sources of data • Primary • Client

Assessment – Data Collection • Secondary • Family and significant other • Medical records • Other records • military, employment • Literature review • Nurse’s experience

Assessment. Methods of Data Collection • Interview • Orientation • Working • Termination • Interview techniques • Open-ended questions • Back channeling • Closed ended questions

Assessment – Methods of Data Collection • Nursing health history • • • Biographical information Reason seeking health care Client expectations Present illness or health concerns Health history Family history

Assessment – Methods of Data Collection • Physical examination • • Vital signs Any other objective measurements Inspection Palpation Percussion Auscultation Olfaction

Assessment – Methods of Data Collection • Diagnostic and laboratory results • Laboratory data • X-rays

Assessment Process • Nursing judgments • Data validation and interpretation • Data clustering • Documentation

Chapter 17 Nursing Diagnosis

Nursing Diagnosis • Definition • A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes • Evolution • Introduced 1950 • 1973 the 1 st national conference held to identify nursing functions and establish a classification system for classification of nursing diagnosis

Nursing Diagnosis • NANDA (North American Nursing Diagnosis Association) • Established 1982 • “To develop, refine, and promote a taxonomy of nursing diagnosis terminology of general use for professional nurses” • Incorporated into ANA Standards of Nursing Practice • Pp. 301 -302 Fundamentals text • Critical thinking approach • Diagnostic reasoning and judgment

Diagnostic Process • Analysis and interpretation of data • Recognizing patterns or trends • Comparing them with standards • Coming to a reasonable conclusion

Diagnostic Process • Identification of client needs • Considers all assessment data focusing on pertinent, relevant, and abnormal data • However, focuses on more than client’s illness or medical diagnosis—self-care needs, psychosocial, etc

Critical Thinking and the Nursing Diagnostic Process

Steps of Data Analysis • Recognize a pattern or trend • Examines clusters of data • set of s/s grouped together in logical order • Defining characteristics • Assessment data that validates nursing diagnosis • Compare with standards for normal healthful patterns • Normal lab data • Normal diagnostic test value

Steps of Data Analysis • Make a reasoned conclusion • Defining characteristics not w/in healthy norms isolated & form basis for problem identification

Types of Diagnoses • Actual • Human responses to health conditions/life processes that exist in an individual, family or community • Examples of diagnostic labels • Acute pain • Ineffective airway clearance • Anxiety

Types of Diagnoses • Risk • Human responses to health conditions/life processes that may develop • Examples of diagnostic labels • Risk for impaired skin integrity • Risk for infection • Risk for powerlessenss

Types of Diagnoses • Wellness • Human responses to levels of wellness in an individual, family or community that have a readiness for enhancement • Examples of diagnostic labels • Family coping: potential for growth • Readiness for enhanced community coping

Components • Diagnostic label • Name of NANDA approved nursing diagnosis • Related factors—etiology • Causative or contributing factors • 4 categories • Pathophysiological • Treatment-related

Components • Situational • Maturational • Phrase: “Related to” • Identifies etiology or cause of client’s response • Etiology • Cause of nursing diagnosis • Must be w/in domain of nursing that responds to nursing interventions

Components • Is not same as medical diagnosis • Ineffective airway clearance related to poor coughing technique • Anxiety related to social isolation secondary to protective isolation • Risk for infection related to indwelling Foley catheter

Components • Definition • NANDA approved definition for each diagnosis • Risk factors that increase client vulnerability • • • Environmental Physiological Psychological Genetic Chemical elements

Components • Support of the statement • Nursing assessment data must support diagnostic label • Related to factors must support etiology

Sources of Errors • Data collection • • New student approach assessment in steps Accurate Complete Use organized approach • Interpretation and analysis of data • Validate subjective data with objective physical findings as necessary • Identify and organize relevant assessment patterns to support present of client problems

Sources of Errors • Clustering • Avoid premature clustering of data • Nurse makes a nursing diagnosis before all data is grouped • Avoid trying to make nursing diagnosis fit s/s • Diagnostic statement • Use standardized nursing language • NANDA

Avoiding and Correcting Errors • Identify the client’s response • Not medical diagnosis • Identify a NANDA statement • Rather than a symptom • Identify a treatable etiology • Rather than a clinical sign or chronic problem

Avoiding and Correcting Errors • Identify the problem caused by a treatment or diagnostic study • Rather than the treatment of study itself • Identify the client response to equipment • Rather then the equipment itself • Identify the client’s rather than the nurse’s problems or interventions • Patient specific

Avoiding and Correcting Errors (cont’d) • Identify the client’s problem rather than the goal • Make a professional judgment • Rather than prejudicial judgments • (subjective and objective data only) • Avoid legally inadvisable statements • Statements that imply blame, negligence or malpractice

Avoiding and Correcting Errors (cont’d) • Identify the problem and etiology • Avoid circular statement • Identify only one problem in the diagnostic statement

Chapter 18 Planning Nursing Care

Planning • Client centered goals and expected outcomes are established • Nursing interventions are selected

Planning • Establishing priorities • Ranking nursing diagnosis in order of importance • Determining client-centered goals and outcomes • Selecting nursing interventions

Planning (cont'd) • Priorities • High • • Maintaining adequate oxygenation Safety Providing comfort Can be psychological • Intermediate • Non-emergent, non-life threatening • Low • Long-term health care needs, education

Planning (cont'd) • Goals-Guidelines • Client centered • specific and measurable behavior or response that reflects a clients' highest possible level of wellness and functioning • “Client will remain free from infection” • Partner with client during goal setting • Ensures adherence to plan of care

Planning (cont'd) • Time limited • Goals should not only meet immediate needs but strive toward prevention and rehabilitation • Short term • Usually less than a week • “Client will achieve comfort within 24 hours” • Long term • Usually over weeks or months • “Client will adhere to post-operative activity restrictions for 1 month”

Outcomes • Specific measurable change in a client’s status that is expected to occur in response to nursing care • Measurable • “Client will report pain acuity less than 4 on a scale of 0 to 10”

Outcomes • Progressive steps • Provide direction for selection and use of nursing interventions • Linked to goals and nursing diagnoses • Objective criteria for evaluating effectiveness of nursing interventions

Goals and Outcomes • Guidelines • Client centered • Reflect client behavior, not nurse’s • “Client will ambulate in the hall 3 times a day” not “Ambulate in hall 3 times a day” • Singular • Each goal or outcome should only address ONE behavior or response • Observable changes

Goals and Outcomes • Measurable • Use terms describing quantity, quality, frequency, length, or weight • Do not use terms such as: normal, stable, sufficient • Time limited • Short or long term, given time in hours/days

Goals and Outcomes • Mutual • Client and nurse agree upon • Realistic • Setting goals that are achievable

Combining Goal and Outcome Statements • “Client will achieve pain control as evidence by reporting pain acuity less than a 4 on a scale of 0 to 10 within 48 hours” • Goal portion of statement provides a broad description of desired client status • Achieving pain control • Outcome portion contains the observable criteria needed to measure success • 4 on a pain scale

Nursing Interventions • Types • Nurse initiated • Independent response of nurse to client’s health care needs and nursing diagnosis • Nurse is able to work within his/her scope of practice on client’s behalf • Based on scientific rationale (EBP) • Do not require a physician’s order

Nursing Interventions (cont'd) • Physician initiated • Manage a medical diagnosis • Physicians written orders • Standing orders • Treatment protocols • Individual written orders • Collaborative • Multiple health care professionals • Nursing • Therapy (occupational, physical, speech) • Nutritionist

Nursing Interventions (cont'd) • Selection criteria • Characteristics of nursing diagnosis • Interventions must be directed toward altering etiological (related to) factors • When an etiological factor can’t change, intervention directed toward treating s/s • Risk for diagnosis, interventions aimed at altering or eliminating the risk factors for diagnosis

Nursing Interventions (cont'd) • Expected outcomes • Specified before selecting intervention • Stated in terms used to evaluate effectiveness of intervention • Research base • Supports nursing intervention (EBP) • When research not available, use scientific principles or consult clinical expert

Nursing Interventions (cont'd) • Feasibility • Specific intervention may have potential for interacting with other interventions chosen by nurse • Nurse must be knowledgeable of total plan of care • Consider: will intervention be clinically effective and cost efficient? • Consider: are time and personal available? • Acceptability to the client • Intervention must be acceptable to client/family • Client must make informed decision

Nursing Interventions (cont'd) • Nurse competencies • Nurse must be able to carry out interventions • Nurse must be knowledgeable of scientific rationale for intervention • Nurse must possess the necessary psychosocial and psychomotor skills to complete intervention • Nurse must be able to function w/in particular setting to effectively utilize health care resources

Care Plans • Guide for clinical care • Serves as a document to communicate a client’s nursing care to all members of health care team

Care Plans • Student • Institution • Kardex • Computerized • Community-based settings • Critical pathways • Allows staff from all disciplines to develop integrate car plan • Concept maps • Diagram of client problems and interventions; shows relationships to one another

Critical Thinking and the Process of Planning

Concept Map: Nursing and Medical Diagnosis

Concept Map Data to Support Nursing Diagnoses.

Concept Map Relationships Between Nursing Diagnoses

Chapter 19 Implementing Nursing Care

Implementation • Begins after care plan has been developed • Nursing Intervention • Any treatment , based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes

Types of Nursing Interventions • Nurse initiated, physician initiated, collaborative • Direct • Treatments performed through interaction with client • IV therapy, med administration • Indirect • Treatments perform away from client but on behalf of client or groups of clients • Infection control, documentation

Types of Nursing Interventions • Protocols • Written plan specifying procedures to be followed during care of clients with a select clinical condition or situation and standing orders • Ex. : Post-op

Types of Nursing Interventions • Standing Order • Pre-printed document with orders for routine therapies, monitoring guidelines and/or diagnostic procedures for specific clients with identified clinical problems • Ex. : ICU • Must be approved and signed by prescribing MD before implementation

Choosing Nursing Interventions • Critical thinking and selection of nursing interventions (6 factors) • Nursing diagnosis • Altering etiological factors • Expected outcomes • Criteria used to judge interventions success • Evidence based • Research, proven practice guidelines

Choosing Nursing Interventions • Feasibility • How will proposed intervention affect other planned interventions? • Acceptability (to the client) • Summarize for client • Informed decision making • Nurse competencies • Nurse must be competent to perform the intervention

Critical Thinking and the Process of Implementing Care

Implementation Process • Reassessing the client • Partial assessment may focus on one dimension of the client • Determines whether proposed intervention is still appropriate • See cast study

Implementation Process • Reviewing and revising the existing care plan • If there has been a change in client status and the nursing diagnosis & related intervention are no longer appropriate, care plan needs to be revised

Modification of Care Plan: 4 Steps • Data in assessment column revised to reflect client’s current status • Revise nursing diagnosis • Delete non-relevant nursing diagnosis • Add new nursing diagnosis • Revise related factors • Revised specific interventions so they corresponds to new nursing diagnosis and client goals • Determine evaluation methods/outcomes • See case study

Implementation Process (cont'd) • Organizing resources and care delivery • • • Equipment Personnel Environment Client Anticipating and preventing complications Identifying areas of assistance

Implementation Skills • Cognitive skills • Interpersonal skills • Psychomotor skills

Direct Care Measures • • Activities of daily living (ADLs) Instrumental activities of daily living Physical care techniques Counseling Teaching Controlling for adverse reactions Preventive measures

Indirect Care Measures • Communicating nursing interventions • Delegating, supervising, and evaluating the work of other staff members

Chapter 20 Evaluation

Evaluation • Final step of nursing process • Is crucial to determine whether the client’s condition or well-being improves • Nurse compares client behavior and responses assessed before nursing intervention with behaviors and responses after administering nursing care

Evaluation • Positive evaluation • Desired results are met • Lead nurse to conclude nursing interventions were effective • Negative evaluation • Client’s inability to meet expected outcomes • Indicate interventions are not effective in minimizing or resolving actual problem

Evaluation Process • Identifying evaluative criteria and standards • Goals • Specifies expected behavior or responses • Expected outcomes • Expected measurable results • Statements of progressive, step by step responses or behaviors that a client needs to accomplish to achieve goals of care • Collecting data to determine if criteria or standards are met • Primary source of evaluation data • Client

Evaluation Process • Interpreting and summarizing findings • Compares expected and actual findings • Documenting findings • Objective • Subjective • Terminating, continuing, or revising the care plan • Goal is met • That portion of care plan is discontinued • Unmet or partially unmet goals • Continue and revise care plan

Success of Goals • Examine the goal statement • Assess the client • Compare the outcome with client behavior or response • Judge the degree of agreement between outcome and client response • Determine reasons for no agreement or partial agreement

Care Plan Revisions • Discontinuing • Outcomes are met successfully, care plan documented as discontinued • Modifying • Reassessment • Ensures database is accurate and current • Nursing diagnosis • Determine if current nursing diagnosis are accurate • Revise/new diagnosis • Client goals and outcomes • Revise if unrealistic or inappropriate • Nursing interventions • If unsuitable either revise or discontinue

Quality Improvement • Approach—purpose • All health care professionals are responsible for evaluating their practices, incorporating EBP into care, and to measuring success of meeting client outcomes • Outcome management • “Managing individual client outcomes of clients as a result of prescribed treatments” • Professional outcomes • Measures of professional caregiver’s performance • Client outcomes • Measures of client’s status after receiving care

Example of a Goal, Outcome, and Evaluative Measure • Goal: client’s pressure ulcer will heal within 7 days • Outcome: erythema will be reduced in 2 days • Evaluative measure: inspect color, condition, and location of pressure ulcer

Chapter 21 Managing Client Care

Building a Nursing Team • An empowered nursing team begins with the nurse executive. • The nurse executive, nurse manager, and staff nurse work collaboratively to create an empowering work environment.

Nursing Care Delivery Models Team nursing: Total client care: Team members provide The RN works directly care under the with the client. supervision of an RN. Primary nursing: Case management: RN assumes a caseload RN maintains of clients during their responsibility for client entire stay. care from admission to discharge.

Decentralized Decision Making • Occurs at the unit level • Includes responsibility, autonomy, authority, and accountability • Staff involvement: • • • Shared governance Nurse-physician collaborative practice Interdisciplinary collaboration Communication Education

Leadership Skills for Nursing Students Clinical decision making Priority setting Organizational skills Use of resources Time management Evaluation Team communication Delegation