Professional Documents
Culture Documents
Theoretical Foundations
of Nursing Practice
Nursing Domain
• What is a domain?
• In science a domain is the view or perspective
of a discipline.
• Nursing’s domain
• Identification and treatment of client’s health
care needs at all levels of health and in all
health care settings.
Nursing Domain
• Person
• Recipient of nursing care
• Health
• Defined in different ways by client
• Environment/setting
• In which health care needs occur
• Nursing
• Creates individualized plan of care
Nursing’s Paradigm (Model)
Types of Theories
• Systems theory
• Basic human needs
• Maslow’s hierarchy of human needs
• Health-and-wellness model
• Stress and adaptation
• Developmental theories
• Psychosocial theories
Maslow's hierarchy of needs
•
Selected Nursing Theories
• Nightingale’s theory
• Focus on the client’s environment
• Henderson’s theory
• Focus on 14 basic needs
Selected Nursing Theories
(cont’d)
• Orem’s theory
• Focus on self-care needs
• Leininger’s theory
• Focus on cultural care
Nursing Process
• Steps
• Assessment
• Nursing diagnosis
• Planning
• Implementation
• Evaluation
Nursing Process
Nursing Process (cont'd)
• Assessment
• Critical thinking approach
• When gathering data the nurse
synthesizes relevant knowledge, clinical
experience, critical thinking standards and
attitudes and standards of practice
simultaneously
• Directs assessment in meaningful and
purposeful way
Nursing Process (cont'd)
• A critical thinker is:
• proactive: anticipates problems, not reactive
• systematic: gathers information, weighs it,
draws conclusions
• logical: bases conclusions on evidence
• persistent: finishes the job
• realistic: settles for a workable solution, not the
ideal solution
Critical Thinking and the
Nursing Process
Critical Thinking in Nursing
Practice
Chapter 15
Critical Thinking
• An active, organized, cognitive process used to
carefully examine one’s thinking and the thinking
of others
• A critical thinker identifies and challenges
assumptions, considers what is important in a
situation, imagines and explores alternatives,
considers ethical principles, applies reason and
logic, and thus makes informed decisions
Aspects of Critical Thinking
• Reflection
• Purposefully thinking back (recalling) a
situation to discover its meaning
• Language
• Use language precisely and clearly;
framing of one’s thoughts so message
is clear
• Intuition
• Direct understanding of a situation
w/out conscience deliberation
Levels of Critical Thinking
• Basic critical thinking
• A learner trusts that experts to have the
right answers for every problem
• Complex critical thinking
• Begins to detach from authorities, analyze
and examine alternatives more
independently
• Commitment
• Nurse anticipates the need to make
choices w/out assistance from others and
then assumes accountability for those
choices
Critical Thinking Competencies
• Scientific method
• Seeking the truth or verifying that a
set of facts agrees with reality;
research
• Problem solving
• Also involves evaluation (follow-up)
• Decision making
• End point in critical thinking, leads to
problem resolution
Critical Thinking
Competencies
• Diagnostic reasoning and inference
• Diagnostic reasoning- process of
determining a client’s health status after
the nurse assigns meaning to behaviors,
physical s/s
• Forming nursing diagnosis
• Inference-drawing of conclusions from
related pieces of evidence
Critical Thinking
Competencies
• Clinical decision making
• Process requires careful reasoning so that
the options for the best client outcomes are
chosen on the basis of client’s condition
and priority of problem
• Criteria to aid in making appropriate
choices
• What needs to be achieved?
• What needs to be preserved?
• What needs to be avoided?
Nursing Process
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
Nursing Process
• Blueprint for care
• Provides a creative, organized framework
for delivery of nursing care
• Can be used in all settings; flexible
Nursing Process
Critical Thinking
• Components
• Knowledge base
• Experience
• Competence
• Attitudes
• Standards
Critical Thinking
Level 3- Commitment
Level 2
Complex
Level 1
Basic
Chapter 16
Assessment - Steps
• Collection and verification of data
• Analysis of data
Assessment - Approaches
• Types of data
• Objective
• Subjective
• Sources of data
• Primary
• Client
Assessment – Data Collection
• Secondary
• Family and significant other
• Medical records
• Other records
• military, employment
• Literature review
• Nurse’s experience
Assessment-
Methods of Data Collection
• Interview
• Orientation
• Working
• Termination
• Interview techniques
• Open-ended
questions
• Back channeling
• Closed ended
questions
Assessment –
Methods of Data Collection
• Nursing health history
• Biographical information
• Reason seeking health care
• Client expectations
• Present illness or health concerns
• Health history
• Family history
Assessment –
Methods of Data Collection
• Physical examination
• Vital signs
• Any other objective measurements
• Inspection
• Palpation
• Percussion
• Auscultation
• Olfaction
Assessment –
Methods of Data Collection
• Diagnostic and laboratory results
• Laboratory data
• X-rays
Assessment Process
• Nursing judgments
• Data validation and interpretation
• Data clustering
• Documentation
Chapter 17
Nursing Diagnosis
Nursing Diagnosis
• Definition
• A clinical judgment about individual, family,
or community responses to actual and
potential health problems or life processes
• Evolution
• Introduced 1950
• 1973 the 1st national conference held to
identify nursing functions and establish a
classification system for classification of
nursing diagnosis
Nursing Diagnosis
• NANDA (North American Nursing Diagnosis
Association)
• Established 1982
• “To develop, refine, and promote a taxonomy of
nursing diagnosis terminology of general use for
professional nurses”
• Incorporated into ANA Standards of Nursing
Practice
• Pp. 301-302 Fundamentals text
• Critical thinking approach
• Diagnostic reasoning and judgment
Diagnostic Process
• Analysis and interpretation of data
• Recognizing patterns or trends
• Comparing them with standards
• Coming to a reasonable conclusion
Diagnostic Process
• Identification of client needs
• Considers all assessment data focusing on
pertinent, relevant, and abnormal data
• However, focuses on more than client’s illness or
medical diagnosis—self-care needs, psychosocial,
etc
Critical Thinking and the Nursing
Diagnostic Process
Steps of Data Analysis
• Actual
• Human responses to health
conditions/life processes that exist in
an individual, family or community
• Examples of diagnostic labels
• Acute pain
• Ineffective airway clearance
• Anxiety
Types of Diagnoses
• Risk
• Human responses to health conditions/life
processes that may develop
• Examples of diagnostic labels
• Risk for impaired skin integrity
• Risk for infection
• Risk for powerlessenss
Types of Diagnoses
• Wellness
• Human responses to levels of wellness in
an individual, family or community that
have a readiness for enhancement
• Examples of diagnostic labels
• Family coping: potential for growth
• Readiness for enhanced community coping
Components
• Diagnostic label
• Name of NANDA approved nursing
diagnosis
• Related factors—etiology
• Causative or contributing factors
• 4 categories
• Pathophysiological
• Treatment-related
Components
• Situational
• Maturational
• Phrase: “Related to”
• Identifies etiology or cause of client’s response
• Etiology
• Cause of nursing diagnosis
• Must be w/in domain of nursing that responds
to nursing interventions
Components
• Is not same as medical diagnosis
• Planning
• Client centered goals and expected
outcomes are established
• Nursing interventions are selected
Planning
• Establishing priorities
• Ranking nursing diagnosis in order of
importance
• Determining client-centered goals and
outcomes
• Selecting nursing interventions
Planning (cont'd)
• Priorities
• High
• Maintaining adequate oxygenation
• Safety
• Providing comfort
• Can be psychological
• Intermediate
• Non-emergent, non-life threatening
• Low
• Long-term health care needs, education
Planning (cont'd)
• Goals-Guidelines
• Client centered
• specific and measurable behavior or
response that reflects a clients' highest
possible level of wellness and functioning
• “Client will remain free from infection”
• Partner with client during goal setting
• Ensures adherence to plan of care
Planning (cont'd)
• Time limited
• Goals should not only meet immediate needs
but strive toward prevention and rehabilitation
• Short term
• Usually less than a week
• “Client will achieve comfort within 24 hours”
• Long term
• Usually over weeks or months
• “Client will adhere to post-operative activity
restrictions for 1 month”
Outcomes
• Specific measurable change in a client’s
status that is expected to occur in response
to nursing care
• Measurable
• “Client will report pain acuity less than 4 on a
scale of 0 to 10”
Outcomes
• Progressive steps
• Provide direction for selection and
use of nursing interventions
• Linked to goals and nursing
diagnoses
• Objective criteria for evaluating
effectiveness of nursing interventions
Goals and Outcomes
• Guidelines
• Client centered
• Reflect client behavior, not nurse’s
• “Client will ambulate in the hall 3 times
a day” not “Ambulate in hall 3 times a
day”
• Singular
• Each goal or outcome should only
address ONE behavior or response
• Observable
• Observable changes
Goals and Outcomes
• Measurable
• Use terms describing quantity, quality,
frequency, length, or weight
• Do not use terms such as: normal, stable,
sufficient
• Time limited
• Short or long term, given time in hours/days
Goals and Outcomes
• Mutual
• Client and nurse agree upon
• Realistic
• Setting goals that are achievable
Combining Goal and Outcome
Statements
• “Client will achieve pain control as
evidence by reporting pain acuity less than a
4 on a scale of 0 to 10 within 48 hours”
• Goal portion of statement provides a broad
description of desired client status
• Achieving pain control
• Outcome portion contains the observable
criteria needed to measure success
• 4 on a pain scale
Nursing Interventions
• Types
• Nurse initiated
• Independent response of nurse to
client’s health care needs and nursing
diagnosis
• Nurse is able to work within his/her
scope of practice on client’s behalf
• Based on scientific rationale (EBP)
• Do not require a physician’s order
Nursing Interventions (cont'd)
• Physician initiated
• Manage a medical diagnosis
• Physicians written orders
• Standing orders
• Treatment protocols
• Individual written orders
• Collaborative
• Multiple health care professionals
• Nursing
• Therapy (occupational, physical, speech)
• Nutritionist
Nursing Interventions (cont'd)
• Selection criteria
• Characteristics of nursing diagnosis
• Interventions must be directed toward
altering etiological (related to) factors
• When an etiological factor can’t
change, intervention directed toward
treating s/s
• Risk for diagnosis, interventions aimed
at altering or eliminating the risk factors
for diagnosis
Nursing Interventions (cont'd)
• Expected outcomes
• Specified before selecting intervention
• Stated in terms used to evaluate effectiveness
of intervention
• Research base
• Supports nursing intervention (EBP)
• When research not available, use scientific
principles or consult clinical expert
Nursing Interventions (cont'd)
• Feasibility
• Specific intervention may have potential for
interacting with other interventions chosen by
nurse
• Nurse must be knowledgeable of total plan of
care
• Consider: will intervention be clinically effective
and cost efficient?
• Consider: are time and personal available?
• Acceptability to the client
• Intervention must be acceptable to client/family
• Client must make informed decision
Nursing Interventions (cont'd)
• Nurse competencies
• Nurse must be able to carry out interventions
• Nurse must be knowledgeable of scientific
rationale for intervention
• Nurse must possess the necessary
psychosocial and psychomotor skills to
complete intervention
• Nurse must be able to function w/in particular
setting to effectively utilize health care
resources
Care Plans
• Cognitive skills
• Interpersonal skills
• Psychomotor skills
Direct Care Measures
Evaluation
Evaluation
• Final step of nursing process
• Is crucial to determine whether the client’s
condition or well-being improves
• Nurse compares client behavior and
responses assessed before nursing
intervention with behaviors and responses
after administering nursing care
Evaluation
• Positive evaluation
• Desired results are met
• Lead nurse to conclude nursing interventions
were effective
• Negative evaluation
• Client’s inability to meet expected outcomes
• Indicate interventions are not effective in
minimizing or resolving actual problem
Evaluation Process