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Chapter 33: Introduction to the Nursing Process:Key Concept:The nursing process is a fundamentally unique problem-solving process that highlights the difference in roles between licensed personnel and unlicensed personnel. The nursing process not only includes the actions involved in tasks but also integrates critical thinking.Problem-Solving:Problem solving is the basic skill of identifying a problem and taking steps to resolve it.Trial and Error:Trial and error problem-solving is an experimental approach that tests ideas to decide which methods work and which do not.Scientific Problem-Solving:Scientific problem solving allows researchers to discover the best possible safe and effective treatments for disease or dysfunction. Seven steps of scientific problem solving:Identify your problem.Gather information relative to the problem.Formulate tentative solutions (hypotheses); choose preferred solution.Plan action to test suggested solution.Experiment and observe the results.Interrupt the results (draw conclusions); understand what the results mean.Evaluate the solution, either concluding or revising the study to test the solution again if results are unsatisfactory.(Requires both logical thought and imagination).Critical Thinking:Critical Thinking: Complicated mix of inquiry, knowledge, intuition, logic, experience, and common sense.The Nursing Process:As a nurse, you combine critical thinking skills with a scientific problem-solving method to identify client problems and to provide care in a structured, purposeful, and effective way. This is the nursing process.Nursing Care Plans: Guidelines used by healthcare facilities to plan the care for clients.Potential Needs: “potential problems” are those problems that might be prevented or problems that the client is at risk for developing.Nursing Alert: Each State’s Nursing Board may define the roles of LPN/LVNs and RNs differently, especially when discussing the initiation and utilization of the nursing process. Know the Nurse Practice Act and the local regulations for your location and situation.Steps in the Nursing Process:Nursing Assessment: They systematic and continuous collection of data.Nursing Diagnosis: The statement or label of the client’s actual or potential problem.Planning: The development of goals for care and possible activities to meet them.Implementation: The giving of actual nursing care.Evaluation: The measurement of the effectiveness of nursing care.Characteristics of the Nursing Process:Systematic: The nurse follows specific, orderly, or logical steps based on the client’s most important and often most vital needs, this is also known as prioritization or prioritizing.Client Oriented: The needs of the client are identified, not the needs of the nurse, family or other healthcare providers. The client, and if appropriate, the family or significant others become the nurse’s partner in determining the goals for care.You, as the nurse, focus on meeting individualized client needs, rather than on performing specific skills.Nurses focus on the rationale of tasks, rather than just the completion of tasks.Goal Oriented: Goals, objectives, or expected outcomes are established as an early part of the nursing process. The client, family and significant others help determine the goals.Short Term Goals: Measurable outcome that can be achieved in hours, days, or weeks, depending on the individual problem.Long Term Goals: Take the short-term goals into consideration, but also provide guidance for the days, weeks, or months during and after the time a client is seen by a health provider.Continuous: Reassessment of the client’s needs is done frequently, sometimes hourly (or more frequently in critical care settings). The existing nursing process must be redesigned spontaneously to fit the most current and high priority needs. The nurse must continually reassess, make new goals, implement new plans, insert new interventions, and re-evaluate the success of the overall process.Dynamic: The nursing process is dynamic and ever-changing. Steps often overlap and sometimes they occur all at munication and Quality Care: The nursing process is a method of communication. The nursing process indicates the effectiveness, or quality, of nursing care. The quality of care can be documented as a goal that is completed, as written in the original care plan, or as a new goal, that is rewritten as a result of evaluation of the goals. A quality care plan also may suggest that the features, interventions, or goal of the original plan need changes.Figure 33-2: Nursing and clients work together as partners to:Promote healthPrevent disease/illnessRestore healthFacilitate coping with altering functioningKey Concept:The nursing process is scientific, systemic, client-oriented, goal-oriented, continuous, and dynamic. The nursing process consists of the following steps:Nursing assessmentNursing diagnosisPlanningImplementationEvaluationThe steps may overlap, change, repeat themselves, or happen all at once.NANDA: North American Nursing Diagnosis AssociationInterventions: You need a source and a rationale.Ineffective airway clearance R/T inflammation of the lungs AMB use of accessory muscles.Impaired comfort R/T wound on left heel AMB facial grimacing. ................
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