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 Processes
Learning 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)
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Health 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

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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
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

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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
Lecture b
Factors That Affect
Affects Clinical Judgment
Clinical judgment is influenced by the nurses
education, experience, values, and other issues

Clinical judgment might reflect a nurses biases
or prejudices
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
Lecture b
The Role of Intuition
in 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

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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
Lecture b
Evidence-Based Decision Making
A type of decision-making that uses research,
the nurses 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
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
Lecture b
The Role of Critical Thinking
in Clinical Judgment
Critical thinking:
Focuses on accurate, reasonable, and fair
solutions to problems
Helps nurses avoid bias
Improves with reflection

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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
Lecture b
Examples of Clinical Decisions
A nurse modifies breastfeeding recommenda-
tions to improve a patients well-being

A nurse chooses an intervention that is least
likely to harm a hospitalized infant
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
Lecture b
The Nursing Process
A 5-step system that uses the nurses 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
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
Lecture b
Assessing
Assessment can include:
Asking questions
Looking at physiologic data (shows how the
patients body is functioning)
Examining the patient
Putting the problem in context
Checking the patients and familys educational
needs

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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
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 patients
response changes
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
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
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
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
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
Lecture b
Evaluating
The plan of care might be changed if:
The patients health changes
Resources change

Evaluation is ongoing

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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
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
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
Lecture b
Legal Issues: Informed Consent
and 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 patients
health information private


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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
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
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
Lecture b
The Nurses Role in Quality
Improvement
Nurses can play many roles in improving
healthcare:
Develop standards of care
Participate in institutional reviews
Report medication errors

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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
Lecture b
Nursing Care Processes
Summary Lecture b

In making clinical judgments, nurses rely on 2
types of information:
Objective (based on facts)
Subjective (based on the patients inner experiences)
Clinical judgment is used by nurses in the 5-
nursing process
Nurses also help protect patients legal rights
and improve patient care
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
Lecture b
Nursing Care Processes
References 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.


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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
Lecture b
Nursing Care Processes
References 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.
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Nursing Care Processes
Lecture b