Mrs. Mendosa delivered a baby with congenital defects yesterday and is being discharged later today. You are responsible for her discharge plan- ning, which includes the need for education about how to feed her infant. The baby is expected to be discharged in approximately 2 to 3 weeks. Think of the priority needs of Mrs. Mendosa. What follow-up care will be necessary for her and the infant? Which community agencies are available to provide sup- port for both mother and child?
NURSINGCHECKLIST
Examples of Critical Thinking Questions for Use with the Nursing Process
l ASSESSMENT
Are the data complete? What other data do I need?
What are some possible sources of those data? What assumptions or biases do I have in this situation?
What is the client’s point of view? Are there other points of view?
l DIAGNOSIS
What do these data mean? What else could be hap- pening? Are there any gaps in the data? How are these data similar and how are they different? What assumptions or biases do I have in this situation?
Have my assumptions affected my interpretation of the data? If so, in what way?
l OUTCOME IDENTIFICATION AND PLANNING What are the goals for this client? What do I want to accomplish? How are my goals related to what the client wants to accomplish? What are the expected outcomes for this client? What interventions are to be used? Who is the best-qualified person to per- form these interventions? How much involvement can the client and family or significant others have at this time? How much involvement does the client wish to have at this time?
l IMPLEMENTATION
What is the client’s current status? What are the most critical steps in this intervention? How must I alter the intervention to best meet this client’s needs and maintain principles of safety? What is the cli- ent’s response during and after the intervention? Is there a need to alter the intervention in any way? If so, why and how?
l EVALUATION
Were the interventions successful in assisting the cli- ent to achieve the desired goals? How could things have been done differently? What data do I need to make new decisions? Where will I get the data?
Were there assumptions, biases, or points of view that I missed that affected the outcomes? What can be done about these assumptions, biases, or points of view?
KEY CONCEPTS
• Critical thinking, problem-solving, and decision- making skills are essential in nursing.
• Critical thinkers ask questions, evaluate evidence, identify assumptions, examine alternatives, and seek to understand various points of view.
• The nursing process is an organized method of plan- ning and delivering nursing care.
• The nursing process is composed of five steps:
assessment, diagnosis, outcome identification and planning, implementation, and evaluation.
• Assessment is the first step in the nursing process and involves collecting, validating, organizing, cate- gorizing, and recording data.
• The second step in the nursing process involves fur- ther analysis and synthesis of the data and results in a list of nursing diagnoses.
• Planning, the third step in the nursing process, involves prioritizing nursing diagnoses, identifying and writing goals and client outcomes, developing nursing interventions, and recording the plan of care in the client’s record.
• Implementation, the fourth step in the nursing proc- ess, involves performing or delegating nursing activ- ities.
• Evaluation, the fifth step in the nursing process, involves deciding whether the client goals have been met, been partially met, or not been met.
REVIEW QUESTIONS
1. When reviewing a client’s lab results, the nurse must have a knowledge base that includes which of the following types of knowledge in order to think critically?
a. Affective b. Declarative c. Nonjudgmental d. Psychomotor
2. Which of the following phrases accurately describes the nursing process? Select all that apply.
a. Applicable to every setting
b. Can be implemented by unlicensed personnel c. Framework for licensure examination
d. Is a linear process
e. Organized care delivery framework f. Used with adults only
T
ABLE5-6 Application of Critical Thinking to the Nursing Process
ASSESSMENT DIAGNOSIS
OUTCOME IDENTIFICATION
AND PLANNING IMPLEMENTATION EVALUATION
• Gather perti- nent data
• Interpret data
• Keep an open mind by ques- tioning assumptions about data
• Think about what informa- tion to collect
• Determine the significance of data
• Make conclu- sions based on the data
• Develop well- thought-out conclu- sions
• Seek reasons and principles that justify nursing judgments
• Test conclusions against criteria
• Suspend judgment when data are insuffi- cient
• Differentiate essential and trivial data
• Explore alternative actions
• Collaborate with others
• Examine assumptions
• Reframe problems in order to generate sol- utions
• Generate ideas and possible solutions
• Communicate with others to solve com- plex problems
• Accurately report data and clues
• Base action on sound rationale
• Establish standards (criteria) based on logic rather than assumptions
• Analyze course of action
• Critique outcomes
• Evaluate the sound- ness of conclusions
Delmar/Cengage Learning
3. The nurse uses creative thinking in order to a. Express his or her own artistic tendencies b. Individualize care
c. Liven up the work environment d. Please clients and families
4. Which of the following is an example of objective client data?
a. 500 mL of amber-colored urine in collection bag b. Client complaint of nausea
c. Client states pain is 9 on a scale of 1–10 d. Self-report of insomnia
5. A client in the intensive care unit (ICU) has several health problems. Which of the following nursing
diagnoses should be of priority concern to the nurse?
a. Imbalanced nutrition: less than body requirements
b. Impaired skin integrity c. Ineffective airway clearance d. Risk for injury (falls)
6. When referring to a client’s medical record for in- formation, the nurse is using which data source?
a. Analytical b. Primary c. Secondary d. Tertiary
online companion
Visit the DeLaune and Ladner online companion resource atwww.delmar.cengage.comfor additional content and study aids. Click on Online Companions, then select the Nursing discipline.
—JONATHANSWIFT
CHAPTER 6
Assessment
COMPETENCIES
1. Identify major purposes of data collection.
2. Describe three types of assessment.
3. Differentiate subjective and objective data.
4. Identify examples of nursing and nonnursing models used in collecting and organizing data.
5. Describe five methods involved in data collection.
6. Explain the stages of the assessment interview.
7. Outline the elements of the health history and their importance.
8. Describe the purposes of the physical assessment.
9. Discuss assessment techniques used in the physical examination.
10. Discuss the use of data clustering in organizing the information obtained about the client.
11. Identify four types of assessment formats.
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A
ssessment is the first step in the nursing process and includes systematic collection, verification, organiza- tion, interpretation, and documentation of data for use by health care professionals. Effective planning of client care depends on a complete database and accurate interpretation of information. Incomplete or inadequate assessment may result in inaccurate conclusions and incorrect nursing inter- ventions. Proper collection of assessment data guides the decision-making activities of professional nurses.Assessment is the collection and analysis of data that are used in formulating nursing diagnoses, identifying outcomes and planning care, and developing nursing interventions.
This chapter discusses the purpose of assessment, types of assessment, and the use of data in the assessment process.