The Culture of Healthcare Nursing Care Processes Lecture b This material (Comp2_Unit6b) was...

The Culture of Healthcare

Nursing Care Processes

Lecture b

This material (Comp2_Unit6b) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number

IU24OC000015.

Nursing Care ProcessesLearning Objectives

• Learn what nurses do and how they are trained (Lecture a)

• Learn how nurses make clinical decisions and assess patients (Lecture b)

• Learn about the settings where nurses work (Lecture a, c)

• Learn about the procedures nurses perform (Lecture c)

2Health IT Workforce Curriculum Version 3.0/Spring 2012

The Culture of Healthcare Nursing Care Processes

Lecture b

The Nursing Process/Clinical Judgment and Assessing the Patient

This lecture covers:• The nursing process, including clinical judgment• Nurses and legal expectations• Nurses and societal expectations• How nurses help improve patient care



Lecture b

Clinical Judgment

• A skill that helps nurses assess and treat patients

• Includes:– Gathering health information by asking questions,

examining the patient, and other means– Learning about other issues that affect the patient,

such as cultural values

• Used in the nursing process



Lecture b

Factors That AffectAffects Clinical Judgment

• Clinical judgment is influenced by the nurse’s education, experience, values, and other issues

• Clinical judgment might reflect a nurse’s biases or prejudices



Lecture b

The Role of Intuitionin Clinical Judgment

• Cognitive continuum theory: all judgments include both intuition and analysis Intuition = “gut feeling” or insight Analysis = study or reasoning

• Nurses sometimes use intuition in making judgments

• Nurses are more likely to use intuition in stressful situations



Lecture b

Evidence-Based Decision Making

• A type of decision-making that uses research, the nurse’s knowledge and experience, and patient preferences

• Often used when giving patients medication or providing acute care

• For other clinical decisions, nurses often prefer talking to colleagues



Lecture b

The Role of Critical Thinkingin Clinical Judgment

Critical thinking:• Focuses on accurate, reasonable, and fair

solutions to problems• Helps nurses avoid bias• Improves with reflection



Lecture b

Examples of Clinical Decisions

• A nurse modifies breastfeeding recommenda-tions to improve a patient’s well-being

• A nurse chooses an intervention that is least likely to harm a hospitalized infant



Lecture b

The Nursing Process

• A 5-step system that uses the nurse’s clinical judgment skills to provide holistic care:– Assessing the patient– Diagnosing the problem– Creating a plan of care– Implementing the plan– Evaluating the plan

• The nurse documents this process



Lecture b

Assessing

Assessment can include:• Asking questions• Looking at physiologic data (shows how the

patient’s body is functioning)• Examining the patient• Putting the problem in context• Checking the patient’s and family’s educational

needs



Lecture b

Diagnosing

• The diagnosis considers:– Current health problems– Current non-health problems– Risk of future health problems– Possible link to a larger syndrome

• Unlike a medical diagnosis of disease, a nursing diagnosis can change as the patient’s response changes



Lecture b

Planning

• The plan of care can include:– Prioritizing problems– Setting short-term goals– Setting long-term goals

• The plan is discussed with the patient and other healthcare team members

• The nurse makes sure resources are available



Lecture b

Implementing

• Implementation needs to involve the patient

• The nurse might help, teach, counsel, or monitor the patient

• The nurse records how the plan is working



Lecture b

Evaluating

• The plan of care might be changed if:– The patient’s health changes– Resources change

• Evaluation is ongoing



Lecture b

Societal Expectations of Nurses

• Nurses are seen as caring, nurturing, and self-sacrificing

• Nurses need to follow protocols, regulations, and stay up-to-date in their specialty



Lecture b

Legal Issues: Informed Consentand Patient Privacy

• Informed consent: Patient needs to understand the risks and benefits of any diagnostic or treatment procedure

• Patient privacy: Under the law known as HIPAA, healthcare providers must keep the patient’s health information private



Lecture b

Legal Issues: Documentation, Dosing, and Reporting

• Nurses must document all care provided• Nurses must administer medications correctly

Right drug Right patient Right dose Right time Right route (oral, rectal, injection, etc.

• Nurses must report any abuse allegations to authorities

18Health IT Workforce Curriculum

Version 3.0/Spring 2012


Lecture b

The Nurse’s Role in Quality Improvement

Nurses can play many roles in improving healthcare:•Develop standards of care•Participate in institutional reviews•Report medication errors



Lecture b

Nursing Care ProcessesSummary – Lecture b

• In making clinical judgments, nurses rely on 2 types of information:– Objective (based on facts)– Subjective (based on the patient’s inner experiences)

• Clinical judgment is used by nurses in the 5-nursing process

• Nurses also help protect patients’ legal rights and improve patient care



Lecture b

Nursing Care ProcessesReferences – Lecture b

References• American Nurses Association [Internet]. 2011 [cited 2011 Dec 8]. The Nursing Process: A Common Thread

Amongst All Nurses [1 page]. Available from: http://ana.nursingworld.org/EspeciallyForYou/StudentNurses/Thenursingprocess.aspx.

• Cape Fear Community College [Internet]. Undated [cited 2011 Dec 8]. Module 5: Nursing Process [34 pages].

Available from: http://cfcc.edu/pn/documents/Module5.pdf.

• The Center for Critical Thinking and Moral Critique [Internet]. 2011 [cited 2011 Dec 8]. Critical Thinking: Where to Begin [1 page]. Available from: http://www.criticalthinking.org/pages/critical-thinking-where-to-begin/796.

• Mayo AM, Duncan D. Nurse Perceptions of medication errors: what we need to know for patient safety. J Nurs Care Qua. 2004;19(3):209-217. Available from: http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=514523.

• Medi-Smart [Internet]. 2011 [cited 2011 Dec 12]. Nursing Legal Issues: How to Protect Yourself [1 page]. Available from: http://www.medi-smart.com/nursing-articles/nursing-law/legal-issues.

• Resources in Nursing [Internet]. 2008 [cited 2011 Dec 8]. Phaneuf M. Clinical Judgement: An Essential Tool in the Nursing Profession [10 pages]. Available from: http://www.infiressources.ca/myscriptorweb/scripto.asp?resultat=230553.



Lecture b

http://ana.nursingworld.org/EspeciallyForYou/StudentNurses/Thenursingprocess.aspx

http://cfcc.edu/pn/documents/Module5.pdf

http://www.criticalthinking.org/pages/critical-thinking-where-to-begin/796

http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=514523




http://www.medi-smart.com/nursing-articles/nursing-law/legal-issues

Nursing Care ProcessesReferences – Lecture b (continued)

References (continued)• RNCentral.com [Internet]. 2011 [cited 2011 Dec 15]. What Is a Nursing Care Plan and Why Is It Needed? [1

page]. Available from: http://www.rncentral.com/nursing-library/careplans.

• Sque M, Chipulu M, McGonigle D. 2009 [cited 2011 Dec 8]. Clinical decision making. In: Hall M, Noble A, Smith S, eds. A Foundation for Neonatal Care: A Multi-disciplinary Guide. Oxford, UK; Radcliffe; pp. 235-251. Available from: http://www.shop-test.co.uk/books/samplechapter/1483/Hall_final_lowres_chap12-26b247c0rdz.pdf.

• State of Connecticut Department of Developmental Services [Internet]. 2009 [cited 2011 Dec 8]. Nursing Standard: Nursing Process # NS 09.1 [4 pages]. Available from: http://www.ct.gov/dds/lib/dds/health/ns_09_1_nursing_process.pdf.

• Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing. J Nurs Educ.

2006;45(6):204-211. Available from: http://ahn.mnsu.edu/nursing/facultyformsandinfo/thinkinglikeanurse.pdf.

• Thompson C, Cullum N, McCaughan D, Sheldon T, Raynor P. Nurses, information use, and clinical decision making: the real world potential for evidence-based decisions in nursing. Evid Based Nurs. 2004;7:68-72. Available from: http://ebn.bmj.com/content/7/3/68.full.



Lecture b

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