nursing practice. Nurse practice acts hold nurses account- able for demonstrating all the steps in the nursing process when caring for clients. To do less implies negligence.
More detailed discussions of the nursing process can be found in specialty texts and in some of the suggested read- ings at the end of this chapter. Nursing Guidelines 2-1 reiterate the sequence of the nursing process.
Concept mapping(also known as care mapping) is a method of organizing information in graphic or pictorial form (Jitlakoat, 2005). This strategy promotes learning by having the student gather data from the client and med- ical record or a written case study, select significant information, and organize related concepts on a one- or two-page working document. Various formats used include a spider diagram with a central theme such as the client’s medical diagnosis, a hierarchy moving from general to specific, or a linear flow chart (Fig. 2-6). With additional knowledge, students draw lines or arrows to link or correlate relationships within the map. Organizing the data then facilitates identifying nursing diagnoses,
CONCEPT MAPPING
USE OF THE NURSING PROCESS
Pharmacist
CLIENT LPN
Dietitian
MD
Physical Therapist Laboratory
Technician
Unlicensed Assistive Personnel
Respiratory Therapist RN
FIGURE 2-5
•
Members of the health care team.OUTCOMES FROM EVALUATION
TABLE 2-5
ANALYSIS REASON ACTION
The client has reached the goals.
The client has made some progress.
The client has made no progress.
Discontinue the nursing orders.
Check that nursing orders are clear and specific.
Continue care as planned; readjust target date.
Revise the plan by adding nursing interventions or more frequent implementation.
Revise problem list; write new goals and nursing orders.
Add new problems, goals, and nursing orders.
Revise expected date for achievement.
Add new nursing orders; discontinue ineffective measures; readjust target date.
Plan was effective and implemented consistently.
Care has been inconsistent.
Target date was too ambitious.
Client’s response has been less than expected.
The initial diagnosis was inaccurate.
New problems have occurred.
The target date was unrealistic.
Nursing interventions were ineffective.
C H A P T E R 2 ● Nursing Process 25
26 U N I T 1 ● Exploring Contemporary Nursing
• Enables students to organize and visualize relationships between their current academic learning and new, unique client assignments.
• Increases critical thinking and clinical reasoning skills.
• Enhances retention of knowledge.
• Correlates theoretical knowledge with nursing practice.
• Helps students recognize information that they must review or learn to promote safe, appropriate client care.
• Promotes better time management for beginning stu- dents otherwise focused on the composition require- ments of nursing care plans rather than use of the nursing process itself.
A
B
C
FIGURE 2-6
•
Three formats used in concept mapping. (A) Spider dia- gram. (B) Hierarchical arrangement. (C) Linear flow chart.NURSING GUIDELINES 2-1
Using the Nursing Process
❙ Collect information about the client. Data collection is the basis for identifying problems.
❙ Organize the data. Organizing related data simplifies the process of analysis.
❙ Analyze the data for what is normal and abnormal. Abnormalities provide clues to the client’s problems.
❙ Identify actual, risk, possible, syndrome, and wellness nursing diag- noses and collaborative problems. Problem identification directs the nurse to select methods for maintaining or restoring the client’s health.
❙ Prioritize the problem list. Setting priorities targets problems that require the most immediate attention.
❙ Set goals with specific criteria for evaluating whether the problems have been prevented, reduced, or resolved. Goals predict the expected outcomes from nursing care.
❙ Select a limited number of appropriate nursing interventions. The nurse uses scientific knowledge to determine which measures will be most effective in accomplishing the goals of care.
❙ Give specific directions for nursing care. Specific directions promote consistency and continuity among caregivers.
❙ Document the plan for care using whatever written format is acceptable.A written plan provides a means of communication and reference for the nursing team to follow.
❙ Discuss the plan with nursing team members, the client, and family.
Verbally sharing the plan ensures that everyone is informed and goal-directed.
❙ Put the plan into action. Work produces results.
❙ Observe the client’s responses. Evaluating outcomes is the basis for determining the effectiveness of the plan of care.
❙ Chart all nursing activities and the client’s responses.
Documentation demonstrates that the planned care has been implemented and provides information about the client’s progress.
❙ Compare the client’s responses with the goal criteria. If the planned care is appropriate, there should be some measure of progress toward accomplishing goals.
❙ Discuss the progress, or lack of it, with the client, family, and other nursing team members. Pooling resources may provide better alternatives when revising the plan of care.
❙ Change the plan in areas that are no longer appropriate. The nursing care plan changes according to the needs of the client.
❙ Continue to implement and evaluate the revised plan of care. The nursing process is a continuous sequence of actions that is repeated until the goals have been met.
setting goals and expected outcomes, and evaluating the results of the care provided.
Those who use concept mapping report that the technique
• Allows students to integrate previous knowledge with newly acquired information.
CRITICAL THINKING E X E R C I S E S
1. If an unconscious client is brought to the nursing unit, how can a nurse gather data?
2. Three nursing diagnoses are on a client’s plan of care:
Ineffective Breathing Pattern, Social Isolation, and Anxiety.
Which has the highest priority, and why?
3. A nurse, while reviewing a client’s plan of care, notices that the client has made no progress in accomplishing the goal by its projected target date. What actions are appropriate at this time?
NCLEX-STYLE REVIEW Q U E S T I O N S
1. When managing the care of a client, which of the follow- ing nursing actions is most appropriate to perform first?
1. Develop a plan of care.
2. Determine the client’s needs.
3. Assess the client physically.
4. Collaborate on goals for care.
2. According to most nurse practice acts, if a charge nurse assigns a licensed practical nurse to admit a new client, the licensed practical nurse’s primary role is to
1. Create an initial nursing care plan.
2. Gather basic information from the client.
3. Develop a list of the client’s nursing diagnoses.
4. Report assessment data to the client’s physician.
3. At a team conference, staff members discuss a client’s nursing diagnoses. A nursing assistant questions which nursing diagnosis is of highest priority. From the list that follows, the licensed practical nurse is most accurate in identifying
1. Ineffective Airway Clearance 2. Ineffective Coping
3. Deficient Diversional Activity 4. Interrupted Family Processes
C H A P T E R 2 ● Nursing Process 27