NUR 139 MODULE B

Characteristics of a Professional Nurse

• Personal Attributes
• Knowledge Base
• Blended Competencies 
• QSEN Competencies  

Five Considerations for Developing Methods of Critical Thinking

• Purpose of Thinking
• Adequacy of Knowledge
• Potential Problems
• Helpful Resources
• Critique of Judgment

The Nursing Process

• should be systematic, dynamic, and outcome     driven
• Assess the patient to determine the need for nursing care.
• Determine Nursing Diagnoses for actual and potential health problems.
• Identify expected outcomes and Plan care.
• Implement the care.
• Evaluate the results and modify the plan as needed.

ADPIE

• Assessing – performing a nursing assessment
• Diagnosing – making a nursing diagnosis (NANDA) 
• Planning – formulating outcome/goal statements and determining nursing interventions
• Implementing Care - taking action
• Evaluating – evaluating progress toward goal (making revisions when needed)

Step One: Assessment

• Assessments may include: 
  • Initial 
  • Focused 
  • Emergency 
  • Time-Lapsed 
• Differentiate the subjective data from the objective data provided.
• List possible sources of patient data.  
• Circle the sources that you think may be available for you to assess in the long term care environment (clinical setting).
• Discuss methods of collecting data.
• Share ideas for collecting data from your assigned resident in the long term     care environment (clinical setting).

Step Two: Nursing Diagnosis

• A nursing diagnosis is NOT a medical diagnosis!
• Nursing diagnoses are written to describe problems or issues that nurses can treat independently such as activity, pain,     comfort, and tissue integrity or perfusion problems.
• Medical diagnoses identify diseases or sickness, where as nursing diagnoses focus on unhealthy responses to health and illness.
• Problem (from NANDA list) which can be an Actual (present) problem     or a Risk (potential) problem 
  • use  the fundamental list of nursing diagnosis provided on Bb for concept  mapping
  • “Related  to” (“R/T”) or "caused by"
• Etiology 
  • “As      evidenced by” (“AEB”)
• Signs & Symptoms (evidence that the problem exists)
• Risk diagnoses only have a problem and an etiology but no S&S

Step Three: Planning

• Establishing priorities - Prioritizing the nursing diagnoses (Maslow)
• Identifying short/long term goals/outcomes
• Developing nursing interventions

Step Four: Implementation

• Describe what occurs during the implementation phase of the nursing process. 
• Put the plan into action!
• Document interventions and patient responses

Step Five: Evaluation

• Describe what occurs during the evaluation phase of the nursing process.
• Collect data related to outcomes
• Compare data to desired outcomes
• Draw conclusions about problem status
• Continue, modify, or terminate the nursing care plan
• Give a few examples of factors that may influence the patient’s achievement of outcomes.

Nursing Interventions:

• Should be client specific (personalized), realistic, goal oriented, and detail oriented
• A nursing intervention is NOT a physician initiated order

Goal/ Outcome Statement

• The client will … (flip the nursing dx./problem)… As Evidenced By… (list measurable criteria)… include a time frame.