The Nursing Process: Clinical Judgment and Assessing the Patient

The focus of this lecture is: Clinical judgment, nursing process, critical thinking and medication administration.

Clinical judgment is an essential path to acquiring the reflective ability and knowledge to understand the condition and needs of the patients.  It requires intellectual and professional maturity, the ability to pay attention, to reason and summarize gathered data.

Nurses use a variety of resources to make a clinical judgment: they critical think through patient situations, they draw upon theoretical and experiential knowledge and use a process to gather assessment data, select a nursing diagnosis for a problem based on what they have assessed, plan what interventions they want to use to assist the patient and resolve the problem and then they evaluate to see if the interventions have worked.

There are many definitions for what critical thinking is but basely it is a highly individualized complex activity that involves a unique kind of purposeful thinking.  One word that explains critical thinking – Reasoning.

Critical thinking is a commitment to look for the best way, based on the most current research and practice findings.  It requires solid logical reasons for judgments and actions.

Critical thinking it is an upgraded version of the problem solving method.  But besides problem solving, critical thinking focuses on gaining new knowledge and skills, seizing opportunities, and constantly finding ways to do things better.Critical thinkers take time to examine situations in terms of content and context, instead of jumping into action to make personal judgments and clinical decisions or solve problems.

The Nursing Process is an ongoing activity with many steps and constantly changing.

The Nursing process is an organizational framework for the practice of nursing

It is a systematic system central to all nursing care which encompasses all steps taken by the nurse in caring for a patient.

The benefit of following the nursing process when developing a patient’s plan of care is that it is a systematic, orderly method for planning & providing care, it enhances nursing efficiency by standardizing nursing practice, it facilitates documentation of care and creates a common language for the nursing profession and stresses the independent function of nurses.

  1. There are 5 steps to the nursing process. Assessment being the first step, nurses systematically assesses their patients to collect data about a patient that can be used in the development of a care plan.  Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well.

  2. From the information the nurse gathers the second step in the process, nursing diagnosis, is made. There are standard nursing diagnosis that reflects the many actual and potential problems a patient may have that the nurse in her scope of practice can manage and treat. The language in the nursing diagnosis may relate to the medical diagnosis but put in nursing language. An example of this might be a medical diagnosis of COPD but the nursing diagnosis may be “potential for oxygen deficit” based on what the nurse assessed in the patient history and what she observes in the patient.

  3. Outcomes / Planning: Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.

  4. Implementation: Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.

  5. Evaluation: Determining the effectiveness of the implemented action plan either to make needed revisions or restart nursing process. Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.

There are many benefits to the patient when the nursing process is used to develop their plan of care. It provides ongoing continuity of care; prevents duplication; individualizes care; uses evidences based standards to care as the foundation of the plan; encourages client participation; encourages collaboration with other healthcare team members so they better understand the plan of care and can make suggestions when appropriate.

This slide demonstrate that developing a plan of care is complicated with many interacting parts and steps resulting in the need to frequently assess and evaluate how the patient is responding to care.  Analyzing all components of the process is an ongoing activity and being aware of the influences playing into the decision making is crucial to the effectiveness of the plan.

Nursing care is complex and challenging, and as the nurse works to develop the plan of care several components: personal knowledge, experience, attitudes and defined standards of care can influence the decisions the nurse makes for her patients.  The nurse has to think quickly and analysis the data frequently to be sure that the best care is being provided.

The administration of medication is often a chief responsibility of the nurse.  The practice of administering medication involves providing the patient with a substance prescribed and intended for the diagnosis, treatment, or prevention of a medical illness or condition.  The nurse must critical think through the process of administering medications in every step taken to deliver the drug.

There are six essential steps the nurse must think through as she administers medication to the patient, she must be sure she has read the order correctly and considered if the right drug has been ordered, did the pharmacy send the right drug, and is the dose correct. It is the right patient and is the time right and the planned route of administration correct.  All these steps are essential each time the nurse administers a drug to any patient.  Nurses are legally and ethically responsible for ensuring that the patient receives the right medication.  Documentation of the administration of the medication is the sixth step in the process.

Drugs error are very dangerous so many hospital have set into place means of preventing  med errors: computerized dispensing machines, scanning devices for patient names and drug,  individual dosing sent  from pharmacy daily rather than taking meds from a stock bottle. Computerized charting that alerts the nurse to medication times and need for documentation.

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