Sheryl Abelew MSN RN
Chapter 4
 Important
step in the critical thinking
process
 Includes effective time management
 Steve Covey (1989) states you should be
“putting first things first”. There are three
categories “must do, should do, and nice to
do”.
 Develop a time frame for priorities.
***Review box 4-2 Time Management
Procedures
 Use
Maslow’s hierarchy of needs
 Five levels of needs

Physiologic needs


Psychological needs


Affiliation, affection, intimacy
Self-esteem


Safety and security
Love and belonging


Sleep, food, water, movement, comfort
Sense of self worth, self respect, dignity
Self-actualization

Recognition of potential growth, health, autonomy
 Place
Low
 High

in level of priority High, Medium, and
Life threatening, threats to pt safety, pain, and
anxiety, unstable or changes in condition
 Medium

Problems that could result in unhealthy
consequences, like emotional or physical
impairment, but no threat on life
 Low

Problems that can be resolved with minimal
intervention and have little potential to cause
dysfunction
 Four
levels of priority according to Rubenfeld
and Scheffer (1999)

Life Threatening Issues


Safety


Protecting the patient from injury, practicing within
scope of nursing, doing no harm
Patient Priorities


ABC’s
Plan of care based on patient activities and condition
Nursing Priorities

Examine all the patients strengths and health
concerns, moral and ethical and Maslow’s hierarchy of
needs
 Setting
priorities is not linear
 Addresses multiple concerns at the same
time
 Learning to take charge and make efficient
use of time is key in time management
 Making a to do list will help with multitasking

Assessment


Analysis


Select diagnosis and activities
Implementation


Have measureable goals based on Maslow, and prioritize
diagnosis
Plan


Prepare list of needs and diagnosis
Outcome Identification


Obtain complete information and sort and ID problems
Perform immediate actions to prevent harm first.
Highest priority to lowest priority
Evaluation

May require reevaluation and/or adjustments
 Priorities
may change
 Inadequate assessment of clients needs
 Failure to differentiate priority and non
priority tasks
 Accepting others priorities without seeing
the big picture
 Performing tasks that were identified first vs.
those that are a priority
 Completing the easiest task first instead of
the priority
Chapter 5
 “Nursing
Process is considered to be a
specialized form of systematic inquiry or
problem solving process used in drawing
conclusions about the patient’s problems and
the corresponding nursing actions to resolve
problems.” Saucier, Stevens * Williams
(2002).
 Allows
for a consistent use of standards and
standardized language providing for a way to
measure and quantify the effects of nursing
care and interventions
 In order to keep terms consistent, ANA
recognizes NANDA as the official language of
nursing diagnosis, NIC for interventions
classification, and NOC for outcomes
classifications
 Assessment
 Analysis
(Diagnosis)
 Outcome Identification
 Plan
 Implementation
 Evaluation
 Collect
data
 Identify pertinent data
 Recognize deviations from normal
 Validate data
 Sort and Organize data in a logical order
 Identify patterns in the data
 Examine
for unmet needs and strengths and
health concerns
 Focus on problems the nurse can change
 Develop diagnosis based on facts
 Validate the diagnosis
 Establish priorities
 Establish



outcomes
Realistic
Achievable
Measureable
 Collaborate
to review goals to meet needs
 How
to develop your strategies for meeting
nursing interventions
 Use NIC for nursing interventions
 Write plan of care using standardized
language
 Collaborate for planning delivery of care
 Initiate
actions to accomplish goals
 Manage care in order of priority
 Delegate care based on caregiver, acuity,
needs and plan of care
 Intervene as necessary
 Document interventions and response
 Compare
actual vs. expected outcomes
 Communicate findings
 Record attainment of goal
 Review and modify POC based on needs
 Written
documentation of the nursing
process
 See
Box 5-3 for care plan formation
 See
Table 5-5 for sample care plan scenario
Chapter 6
 Transferring
tasks to a competent individual
 Used most commonly with a skill mix based
on scope of practice
 Consider job description when delegating
 Right
Task
 Right Circumstance
 Right Person
 Right Direction and Communication
 Right Supervision and Evaluation
 Delegator
reluctant to take the risk and give
up control
 Subordinate fails to take responsibility
 Workplace issues
 Assessment

List patients need and assessment findings
 Analysis

Level of care and acuity
 Outcome

identification
Establish priorities
 Plan

Nurse specifies nature of tasks and skill required
 Implementation

Delegation of tasks
 Evaluation

Compare outcomes with the POC
Chapter 7
 Three

Social


Interactions for building relationships
Therapeutic


levels of Communication
Nurse listens to patient problems and focuses on needs
Collegial

Enhancing relationships with colleagues, improved pt
care, and better documentation
 Nursing
Personnel
 Delegating
 Report
 Interdisciplinary
 Conflict resolution
 Physician notification
 Receiving phone calls
 Documentation




One way to validate critical thinking
Keep confidential
Accurate and objective
Performed promptly
Chapter 8
 Goal
directed based on rationale thought
processes
 Involves critical thinking
 Approached analytically
4




areas must be assessed
What the patient needs to learn
Characteristics of the patient
Patients preferred learning style
Whether patient is ready/willing to learn
 Conduct
a learning needs assessment
 Assess cultural background
 Developmental stage consideration
 Literacy
 Analyzing

Validate with the patient
 Outcome

identification
ID goals, clear objectives
 Planning

needs
the lesson
Instructional methods


Traditional i.e. lecture, discussion
Non traditional i.e. role-playing, simulations, etc
 Implementing
educational session
 Evaluating the educational process
Chapter 9
 When
processing data, continually evaluate
reasoning
 Examine the evidence to determine what
else is needed
 Obtain and clarify data
 Examine logic and give reasons for
conclusions
 Review the consequences of possible actions
and draw conclusions if desired outcome can
be obtained
 Use
professional standards as guidelines to
decision making when evaluating patient
circumstances, and then consider the
textbook data, current diagnostic test
findings, and assessments of the nurse
 Nurses need to follow the regulations set
forth according to scope of practice and
standards of practice as well as the code of
ethics for nurses when making decisions
 Review box 9-2 pg 199
 Nurse
collects information and uses skill of
interpretation to define what the patient is
presenting as
 Nurse establishes expected outcomes for
interventions to determine if the problem
will be resolved
 After implementation, nurse will evaluate on
an ongoing basis progress towards goals
 After recognizing effects from intervention,
nurse will offer rationale for the result
 Lastly, nurse will reexamine thinking
 Quality
implies evaluation
 Evaluation requires standards which define
the acceptable levels of care
 Nurse must evaluate actions to the
professional practice standards from the ANA
 Indicators





that identify impossible workload
Failure to monitor when indicated by patients
condition
Inadequate treatment for circumstances
Excessive delay of treatments
Failure to provide ongoing care and treatments
Lack of time to provide patient teaching
 Use
clinical reasoning to monitor patients
change of condition and respond with the
appropriate intervention
 Two examples of monitoring the patients
condition

Calling the physician






When there is a change in condition
Pain without ordered meds that manage the pain
Acute elimination problems
Lab values that require orders
Risk to safety
Interpreting lab values



Are the findings abnormal and expected
Are the findings abnormal and unexpected
Are the findings normal
 Failure
to use appropriate decision making
skills
 Failing to assess, report, or omissions
 Failure to assess for changing of condition
 Nurse fails to perform duties appropriately
results in negligence
Chapter 10
 Ethics
deals with the principles of right and
wrong
 Foundation of ethics is standards of conduct
and moral judgment
 Nurses must be aware of their own value
system
 Choosing

Allows for free choice identifying alternatives
and selecting alternatives
 Prizing

Individual satisfaction with choice of
verbalization to others
 Acting
(Internalization and repetition)
Ethical Principles

Autonomy


Nonmaleficence


Moral obligation to treat people fairly and equally
Fidelity


Doing good on the patients behalf
Justice


Directs the nurse does no harm
Beneficence


Right to self-determination
Keeping your word and acting in the patient’s best
interest
Veracity

Telling the truth
 ANA
as developed a code of ethics
 Nine statements define this code
 Review pg 233 Box 10-3
 Assessment
 Analysis
 Outcome
Identification
 Plan
 Implementation
 Evaluation
**
 Gather
information to determine the facts
that will have the most affect on the
situation
 Develop sensitivity to recognize ethical
situation and its essence to nursing
 Identify risks to the patients
 Determine
the values in conflict
 Become aware of the relevant information
 Values clarification
 Generate multiple alternatives and rank in
order of what is right and wrong
 Explore emotional, social and physical risks
to patient and staff
 Providing
safe nursing care
 Expected outcome should serve as a guide in
making decisions
 Use clearly stated outcomes for success to be
measureable
 Decision
maker should choose the best
options for prioritizing of needs to achieve
the desired outcome
 Organize information and alternatives that
represent various moral views
 Be prepared to defend your choice
 Stay focused on the outcome to stay focused
on the real problem
 Implement
the moral action selected to
resolve the dilemma
 Follow chain of command
 Support a blame free environment
 Were
the actions ethical?
 Did the solution generate the desired
outcome?
 Can you justify the consequences?
 Do the benefits outweigh the risks?
 Hospitals
and long term care facilities have
groups of individuals who discuss, clarify, and
resolve issues related to patient care welfare
 Goal is to support objectivity in difficult
patient care decisions
 Best when whole team and patient and
families are involved
 Self-Determination
 Professional

Risk for injury


Usually with the demented, depression, or delirium
Inadequate staffing



Caregiver Issues
Staffing appropriate for acuity of patients
Nurses practicing out of their specialty or knowledge
base
Biomedical advances

Transplants, in vitro, etc.
 Disregard

for others
Using others without considering them
 Inappropriate

Making decisions that another prudent
professional would not make
 Personal

gain
Having ulterior motives
 Conflict

application of standards
of values
Responding to needs without concern for those
affected
Chapter 11
A
skill required in choosing how to meet the
needs of a group of patients
 Requires







Problem solving
Priority setting
Decision making
Good application of the nursing process
Ability to identify variations in patients
Strong knowledge base
Sound nursing decisions
 First


level priorities
Life threatening
Unstable, worsening of condition
 Second


Delay may cause untoward results
Nonemergent

Scheduled meds, mental status changes, acute pain
 Third

level priorities
level priorities
Deficits that can easily be resolved or do not
affect normal function

Bathing, grooming, emotional support
 Review
implications if care/treatment were
to be delayed
 Develop and action plan

Scheduled activities should be primary
consideration
 Determine


who can do it
Consider the roles of available UAP
Evaluate competency of staff
 Nurses
should not refuse because of a lack of
skill
 Focus on what they can do and what they
can help with being supervised
 Educational preparation is ideal
 Review pg 264 Box 11-3
 Review pg 264 box 11-4
 If an assignment is out of scope of practice
submit an occurrence report and request
additional training
 ED
nurses
 Coronary intensive care nurses
 Pediatric nurses
 Obstetric nurses
 Oncology nurses
 Psychiatric nurses
 Medical/surgical nurses
 Consider
circumstances and need
 Gender
 LOC
 Acuity
 Special
needs
 Age
 Medical
dx
 Staffing
 Family
requests
 Failure
to use nursing judgment
 Inability to gather data
 Inadequate decision making
 Inability to prioritize
 Incompetent application of cognitive skills
 Failure to ID impact of action on an outcome