Separating the Professional from the
Technical



“the active, organized, cognitive process
used to examine one’s own thinking and
the thinking of others”
Using reflection, intuition, and previous
experiences to make sound decisions
Requires a habit of asking questions,
remaining well informed, a willingness to
reconsider, and avoiding premature
decision making

Knowledge base
◦ Theoretical
◦ Experiential

Experience
◦ Practice making decisions


Technical Skills & Competencies
Attitudes and behaviors
•Self aware
•Genuine / authentic
•Effective
communicator
•Curious & inquisitive
•Alert to context
•Analytical & insightful
•Logical and intuitive
•Confident & resilient
•Honest
•Responsible &
autonomous
•Careful & prudent
•Open & fair minded
•Sensitive to diversity
•Creative
•Realistic and practical
•Reflective & self-corrective
•Proactive
•Courageous
•Patient & persistent
•Flexible
•Improvement oriented

The Nursing Process: a systematic problem
solving approach consisting of;
◦
◦
◦
◦
◦


Assessment
Diagnosis
Planning
Implementation
Evaluation
Nursing involves both thinking and doing
Nursing deals with complex issues
◦Brings together
Critical thinking
Nursing process
Nursing knowledge
Patient situation
◦Types of Assessment
 Comprehensive
 Focused
 Special needs
 Initial
 Ongoing

Types of Data
◦ Subjective
◦ Objective

Sources of Data
◦ Primary data
 Client
◦ Secondary data
 Family
 Health Records
 Health Team Members
 Methods
of collection
◦ Observation
 Use all 5 senses
◦ Physical assessment
◦ Interview
 Health history


Performed after nursing history
Collection of objective data
◦ Ht., Wt., V.S.
◦ General Survey
◦ Head to toe exam





Inspection
Palpation
Percussion
Auscultation
Olfaction


Biographical Data
Reason for Seeking Health Care / Chief
complaint
◦ Client’s Expectations





History of Present Illness
Past Health History
Family History / social history
Medications
Review of body systems

To ensure data is
◦
◦
◦
◦

accurate
Complete
Factual
And you are not jumping to conclusions
When to validate
◦ Subjective and objective data do not agree
◦ Patient’s statements differ at different times
◦ Data falls outside normal range


Systematic
Usually controlled by agency forms
◦
◦
◦
◦
◦
◦
Body systems framework
Maslow’s Hierarchy of Needs
Gordon’s functional patterns
Orem’s Self care model
Roy Adaptation Model
NANDA nursing diagnosis Taxonomy II


Organizing data into meaningful clusters
A set of signs or symptoms grouped
together into logical order

Groupings of associations

Helps you recognize significant cues

Utilizes critical thinking to
◦ Judge the value or significance of the
data
◦ Validate and verify assumptions with
client and other health care team
members

Identify patterns in data and draw conclusions about
client’s status

Describes client’s actual or potential response to a health
problem

A statement of client health that nurses can identify,
prevent, or treat independently

Stated in terms of unique human responses to diseases,
injuries, or stressors

Must be accurate because it provides direction for nursing
care

Actual (3-part statement)
◦ Presently exists

Risk (2-part statement)
◦ Likely to develop in vulnerable patient

Possible (2 or 3- part statement)
◦ Suspect on intuition but don’t have enough data yet

Syndrome (1 part statement)
◦ Collection of nursing diagnoses that occur together

Wellness (1-part statement)
◦ Not a health problem, wants to move to higher level of wellness

Diagnostic Label (title or name)

Related Factors

Defining Characteristics

◦ Approved by NANDA
◦ Etiology must be in nurses domain to intervene
◦ Don’t use medical diagnoses
◦ Cues from assessment data
◦ must support diagnosis
Eg. Impaired mobility R/T lack of
peripheral sensation AEB inability to walk
from bed to chair.

Data collection
◦ Omitted, incomplete, inaccurate, disorganized

Data analysis & interpretation
◦ Inaccurate interpretation of cues, conflicting cues,
incorrect judgments of inferences

Data clustering
◦ Incorrectly clustered or not clustered at all

Diagnostic Statement
◦ Problem & etiology must be in scope of nursing to
treat






Identify client’s response not medical
diagnosis
One symptom is insufficient for problem
identification
Nursing interventions directed at correcting
etiology of problem
Identify client response to equipment not
the equipment itself
Client problems not nurse problems
Develop in cooperation with client

Nursing diagnosis
◦ Defines nursing needs of clients related to the
medical diagnoses

Medical Diagnosis
◦ Reflects specific disease, illness, or injury
◦ Goal – prescribe treatment

Place in order of importance or urgency

Maslow’s Hierarchy of Human Needs
◦
◦
◦
◦
◦


Physiological
Safety and security
Love and belonging
Self-esteem
Self-actualization
A,B,C’s
Nursing Process

Client centered goals / outcomes
◦
◦
◦
◦
Specific measurable objective
Are precise, descriptive, clearly stated
Reflects highest level of wellness
Should be realistic
◦ Observable client behavior
◦ Measurable criteria for each goal
◦ Projected time frame for goal achievement
◦ Provide a guide for selecting interventions

Short term goals
 Achieve in hours or days, less than 1 week

Long term goals
 Achieved over weeks or months

Subject
◦ The client

Action verb
◦ Action that will be performed by client

Performance criteria
◦ Specific measurement to be evaluated

Target time
◦ When action should be achieved

Special conditions
◦ Amt. of assistance, what equipment, resources
needed







Client centered…
Singular factors/ criteria…
Observable factors…
Measurable factors…
Time limited factors…
Mutual factors…
Realistic factors…







Serves as Written guidelines for client care
Communicates care
Enhances continuity
Organizes information – promotes efficiency
Involves client and family
Meets requirements of accrediting agencies
Care plans help students learn problem
solving, skills of written communication,
organizational skills, and application of
theory

AKA Nursing
◦
◦
◦
◦
Actions
Measures
Strategies
Activities
◦ Actions based on clinical nursing judgment and
knowledge that nurses perform to achieve client
outcomes
◦ Include activities of observation/assessment,
prevention, treatment, & health promotion

Independent
◦ Nurse initiated interventions
◦ In realm of independent nursing practice
◦ No MD order required

Dependent
◦ Physician initiated interventions
◦ Require MD orders

Collaborative (interdependent) interventions
◦ Coordination of multiple professionals

Include activities of







Observation/assessment
Prevention
Therapeutic Treatments
Health promotion
Activities of daily living
Teaching
Discharge planning

Flow from Client goals/outcomes / orders

Individualize standardized interventions

Nursing Orders
◦ Instructions on care plan describing implementation
of interventions
 Include









Date
Subject
Action verb
Times and limits
Signature
Standing Orders
Protocols
Critical Pathways
Evidence Based Practice

Nursing action nonspecific

Fail to indicate frequency

Fail to indicate quantity

Fail to indicate method

Fail to indicate person to perform




Implementation
The action phase of the nursing process
You will perform or delegate planned
interventions
Implementation ends when you record the
nursing actions on chart
◦ Evolves into evaluation as you record resulting
client responses





Check your knowledge and abilities
Organize your work
Prepare the patient
Implement the plan
Coordinate/collaborate
◦ Delegate appropriately





Right
Right
Right
Right
Right
task
circumstance
person
directions / communication
supervision


Planned
Ongoing
◦ Does not end the nursing process

Systematic

Make judgments about
◦ Client’s progress toward expected outcomes/goals
◦ Effectiveness of nursing care plan
◦ Quality of nursing care delivered

Ongoing evaluation
◦ At each contact with patient

Intermittent evaluation
◦ At outcome evaluation specified times

Terminal evaluation
◦ At time of discharge



Review Outcomes
Collect Reassessment Data
Judge Goal Achievement
◦ Achieved (met)
◦ Partially achieved (partially met)
◦ Not achieved (unmet)


Record evaluative statement
Revise care plan if indicated
◦ Begin with assessment data and go through entire
nursing process

Written evidence of interactions
◦
◦
◦
◦
◦
◦
◦
◦
Health professionals
Clients
Families
Health care organizations
Diagnostic tests
Treatments
Education
Client results/responses

Correct client record

Client name on each page

Document immediately

Date and time each entry

Sign each entry with name and professional
credentials

No space between entries

Never change another’s entry

Use “quotes” for client statements

Chronological order









Use appropriate vocabulary / terminology
Only approved abbreviations / symbols
Use organized and logical sequence
State only factual not inferences
Use correct spelling, legible writing
Protect client confidentiality by not releasing
records to anyone without patient permission
Write neatly, legibly, & in ink
Use concrete specific terms
Follow agency guidelines

Source-Oriented Records
◦ Separate sections for each discipline

Problem-Oriented Records
◦ Consists of database, problem list, plan of care, &
progress notes

Narrative

SOAP

PIE

Focus

Charting by exception

Computerized