Clinical Nursing Skills: Basic to Advanced Skills, 9th Edition

Chapter 2 Nursing Process and Critical Thinking TEACHING/LEARNING STRATEGIES Lecture–Discussion Use a nursing diagnosis book to explain in detail how to use nursing diagnosis appropriately. Apply categories to clients in the hospital. Obtain a copy of Nursing Diagnosis Handbook10th ed. Judith Wilkinson (Prentice Hall 2014),Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care, 10th edition. Ackley and Ladwig, C.V. Mosby 2014, Nursing Diagnoses 2015-2017: Definitions and Clarification (NANDA), or Nursing Diagnoses: Application to Clinical Practice, 14th ed.Lynda Carpenito (Lippincott Williams and Wilkins 2012). After reading their description of how to use critical thinking, determine which definitions best fit your curriculum framework. Based on that decision, you can develop a methodology for inclusion of critical thinking into your coursework. Oral Assignment Have students identify a client-based problem and then follow the four steps in the problem-solving process related to Evidence Based Practice. Students need to research the problem using appropriate references. You may need to give them a list of appropriate references. Each student, or student group, should then report their findings to the class. Written Assignment Provide each student with a list of current nursing diagnoses. These could be written on index cards to carry to the clinical setting. Resource Suggestions Critical Thinking and Clinical Judgement: A Practical Approach to Outcome-Focused Thinking, 6th ed., by Alfaro-LeFevre, Rosalinda (Saunders), 2017. CRITICAL THINKING STRATEGIES Exercise 1 One example of how to introduce both critical skills and nursing process into skills and clinical courses is to have a discussion of how critical thinking skills are used throughout the nursing process. Resolution Possibilities for Exercise 1 You can develop your own “thinking system,” incorporating the nursing model you use as your theoretical framework in the program. As an example, if you use the Roy adaptation model, you may have the students state the critical thinking skills according to the specific terminology in the model. The Roy model would list under assessment, first- and second-level assessment behaviors. The students then use that data and cluster ineffective behaviors and form a nursing diagnosis. You then expect them to be able to distinguish relevant from irrelevant data, important from unimportant data. They should also be able to provide a rationale for their answers. You may choose to have the students determine what specific information belongs under each step of the nursing process. They can be given characteristics of each phase in a random order. They are to take each characteristic and place it under the correct phase of the nursing process. After they have placed the characteristics in the appropriate phase of the nursing process, it is a good idea to show multiple-choice test questions that test each phase of the nursing process. Ask the students to identify the phase being tested and provide the rationale for their answer. It may be helpful to administer one of the commercial instruments available on critical thinking to the beginning students and then to the graduating students to determine if an increase in ability to use critical thinking skills has occurred throughout the program. It is important that the faculty look at the many tools available and choose the tool that most represents the definition of critical thinking that is used throughout the nursing program. Scenario 1 You have been assigned to care for Mr. Peters, a 76-year-old widower who was admitted with the diagnosis of congestive heart failure. He has lived alone for the last two years since his wife died. His children live about one hour away and visit him once a month. The children ordered Meals on Wheels for him, but he refused to eat the food that was delivered. “I can do my own cooking. I am not an invalid,” was the answer when the nurse asked why he didn’t like the Meals on Wheels program. He had not seen the physician for at least 2 years. At the last visit, the physician prescribed a moderately low sodium diet, furosemide (Lasix) 40 mg. daily, verapamil (Calan), and multiple vitamins. His admitting vital signs were BP 180/90, P 98, R 22. His weight indicated a gain of 10 pounds since the last visit. His physical assessment indicated rales in the lung bases, 3+ edema of the ankles, and difficulty breathing in a supine position. 1. How will you use the nursing process to determine an accurate data base? 2. What information is missing that might be important to the nurse to assist in planning care for this client? What is the best approach for obtaining the information? 3. Identify at least four nursing diagnoses that are relevant for this client’s plan of care. Write a two-part and a three-part diagnostic statement for each nursing diagnosis. 4. Using a nursing diagnosis book, identify NIC and NOC statements for the four nursing diagnoses listed in question 3. 5. Identify the priority nursing diagnosis, and provide the rationale for your decision. 6. Develop a very brief nursing care plan using the nursing process format as outlined in the text. Note: Scenario 1 can be used as a critical thinking scenario for a beginning student. This is a good scenario for role play. To encourage nurse–client communication and questioning techniques to obtain data, have the students divide into pairs. Give one student in each group (the client) cards with additional information regarding his symptoms and clues on how to answer questions posed by the “nurse.” Have the “nurse” proceed to gather additional data without the use of cards or prompts. After the role play is completed, ask the students to complete the nursing care plan with the information they gathered. After completing the care plan, have the students determine if they gathered sufficient information for the care plan. If not, ask them what data they needed. Scenario 2 8 A.M. You are assigned to a 22-year-old male client who was in a motorcycle crash yesterday. He sustained a compound fracture of the right fibula and tibia. He states his pain is 9/10 and is throbbing. He is nauseated all the time. He is scheduled for surgery later in the day. You assess his wound area and notice there is a large amount of serosanguinous drainage of the dressing. You reinforce the dressing. 1. Based on the information provided in the scenario, identify two nursing interventions. 2. Determine priority nursing diagnoses and provide rationale for your decision. 3. Using a nursing diagnostic textbook, develop a client care plan incorporating NIC and NOC data. Resolution Possibilities for Scenario 1 1. Assessment phase Gathering data Confirming observations Verifying data Nursing Diagnosis Analyze collected data Determine cluster of clues Identify related factors Identify potential nursing diagnosis 2. a. Can he actually cook for himself? b. What are his physical assessment findings related specifically to his heart and lungs? (e.g. heart assessment, particularly the PMI.) c. Who is responsible for his care at home? Can he actually return to his house with/without outside help? d. Is he taking his medications as prescribed? Does he know the action of the drugs and what happens if he doesn’t take them? The best approach is to ask him questions directly and have him state information about his drugs. It may be that the children will also have to answer the questions as well to get a complete picture of Mr. Peters and his ability to care for himself. 3. There are many potential nursing diagnoses. Four common nursing diagnoses for Mr. Peters might include: Excess fluid volume Ineffective role performance Ineffective self-health management Deficient knowledge related to drug therapy Two-part statement (Example) Excess fluid volume related to decreased cardiac output secondary to congestive heart failure Three-part statement (Example) Excess fluid volume related to decreased cardiac output secondary to heart failure as evidenced by peripheral edema, shortness of breath, and weight gain The two statements will be reflective of your identified nursing diagnosis. 4. Information for this answer is dependent on the chosen nursing diagnosis. Example for the excess fluid volume: Electrolyte and Acid-Base Balance: Balance of electrolytes and nonelectrolytes in the intra- and extracellular compartments of the body. Fluid Balance: Balance of water in the intra- and extracellular compartments of the body. Hydration: Amount of water in the intra- and extracellular compartments of the body. 5. Excess fluid volume, is the priority diagnosis. His symptoms all indicate a fluid overload state. This condition can increase his poor cardiac output and place the client in jeopardy for adequate tissue perfusion to vital organs. 6. The care plan should include the following information: Problem/need (nursing diagnosis) Expected outcome/goals Nursing interventions—at least two for each nursing diagnosis Resolution Possibilities for Scenario 2 1. The appropriate nursing diagnoses would be: a. Acute pain. b. Risk for infection. c. Nausea. d. Deficient fluid volume. e. Ineffective coping. f. Disturbed body image. 2. Determine the two highest priority nursing diagnoses: a and b are probably the highest priority. After you have identified the diagnoses and their interventions, refer to a nursing diagnosis textbook to check interventions related to the diagnosis and evaluate the rationale for your selection. 3. The nursing diagnoses most likely considered last would be e and f. Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez © 2017, Education Inc.