Practical nursing clinical (online help)

Jack Fowler

PNC121StudentPPTWeek522213.pptx

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Preparing for Client Care

Nursing Research

Critical Thing & Reasoning

Development of Research in Nursing

Started with Florence Nightingale

First nursing research journal published in Canada was in 1969 called Nursing Papers

Research

Some research tests nursing theories; other research generates theory from findings

Nurse’s examine factors relevant to nursing in the context of the larger health care picture

The scientific knowledge needed for nursing is discovered, tested and enhanced through research

Clinical Research Expectations

Clinical research is dynamic

Needs to be reviewed and updated regularly so that the information is current/relevant

Research Literacy

An essential competency for evidence-informed practice; It is the ability to locate, understand and critically evaluate empirical literature for application in practice

When critiquing evidence first evaluate the scientific merit and clinical applicability of each studies findings

Do the articles together offer evidence to explain or answer your question?

Do the articles show that the evidence is true and reliable?

Can you use the evidence in practice?

Evidence-Based Nursing

The evidence-based nurse knows what needs to be done, how it should be done, and the evidence that supports his or her practice.

“Armed with evidence!”

Evidence-Informed Practice (EIP)

Basing health care decisions upon evidence is essential for quality care in all domains of nursing practice

Evidence-informed clinical decision making is affected by:

Evidence from research and theories

Evidence from patient assessment and health care resources

Clinical expertise

Patient preferences and actions

Steps of the Evidence-Informed Practice Process

RNAO Best Practice Guidelines (BPG)

The Registered Nurses Association of Ontario (RNAO) has developed many Best Practice Guidelines for the use in nursing.

RNAO

Other Credible Resources for Nursing Research

Research articles:

Seneca library: databases for Proquest, CINAHL, Cochrane database, DARE, MEDLINE, EBSCO or Embase

Library tutorial on how to conduct research – see link on your BB site

Research in the Clinical Setting

In clinical, researching information on your patients is synonymous with investigating and looking up information, in order to establish facts.

You need to research all pertinent information about your client's care in order to provide care.

What information do you think you need to research about your patient prior to providing care?

What resources would be used to conduct this research?

Diagnosis Research Template

Let’s take a look at the template you will use in clinical and each of the components

Medical Diagnosis

“A medical diagnosis is the identification of a disease condition on the basis of a specific evaluation of physical signs and symptoms , the client’s medical history, and the results of diagnostic tests and procedures.” (Potter & Perry, 2019, p. 196)

Example of a medical diagnosis

Clinical Manifestations

Relates to signs and symptoms

Signs evident upon examination

Symptoms identified through client history and interview

Examples?

Associated Lab Values and Diagnostic Tests including Normal Values

What types of tests might be used to support a medical diagnosis?

Medical/Surgical Interventions Prescribed by the Physician

Interventions ordered based on medical diagnosis , e.g. medications, catheterization, wound care, g-tube insertion

Can change several times throughout a shift depending on patient acuity

All interventions ordered must be completed and documented.

Nursing Assessments Needed (physical, psychological, social, spiritual, economic)

Can include:

Head to toe assessment

Vital signs information

ADLs

Family concerns

Financial worries, etc…

Common Nursing Diagnoses/Problems

Nursing diagnoses or problems can include an actual problem or an at-risk problem that affects the patient

Includes a diagnostic label of the problem e.g., impaired physical mobility

Plus related factors associated to that diagnosis or problem, e.g., related to pain

Also includes an “as evidenced by” portion relating the problem to the signs and symptoms

Nursing Interventions/Implications

These are the actual things we do for the patient, including the outcome.

It is any treatment based on clinical judgement and knowledge, to enhance client outcomes

Choosing Nursing Interventions

Interventions should alter the signs and symptoms related to the diagnostic label

Interventions should have an expected outcome

Interventions should be evidence-based, research evidence in support of a nursing intervention

Feasibility of successfully implementing the intervention –consider cost and time

Acceptability to the client – must match the client’s goals

Capability of the nurse – current knowledge of the intervention, be prepared to carry it out, know the scientific rationale for the intervention

Independent Nursing Interventions

The things nurses initiate based on their scope of practice, such as bathing, ongoing assessments, making referrals to other health care professionals, initiating wound care, raising an edematous leg etc.

Dependent Nursing Interventions

Interventions prescribed by a doctor or NP order

E.g. medication administration, specific diet, test and treatments

The nurse is still responsible for explaining, assessing the need for, administering and evaluating the medical order.

Assignment 3

This assignment involves completion of the Diagnosis Research Form.

One medical diagnosis is to be researched and completed on the “Diagnosis Research” template that is included in the PNC 121 course outline.

Worth 5% of your grade

The rubric is in the course outline

Maintain APA format when citing resources

Clinical Research Sample

A sample Research Form has been prepared for the medical diagnosis “COPD”

Note the content found under each heading

Note the use of in-text and reference page citations

Note integration of medical-surgical text research and professional nursing journal resources

Critical Thinking

Critical thinking is a complex phenomenon defined as a process acquired through learning and experience.

Requires purposeful and reflective reasoning.

(Potter& Perry, 2019, p. 174-175)

Critical Thinking Model for Nursing Judgement

Involves 3 levels – basic, complex and commitment.

Includes 5 components – specific knowledge base, experience, critical thinking competencies, attitudes and standards

Critical Thinking Model for Nursing Judgement

General Critical Thinking Competencies

The scientific method

Problem solving

Decision making

The Scientific Method

Involves 5 steps

1. Identification of the problem

2. Collection of data

3. Formulation of a research question or hypothesis

4. Testing of the question or hypothesis

5. Evaluation of the results of the test or study

Problem Solving Process

Involves working through a process of recognizing, clearly defining and then solving a problem

The nurse obtains information that clarifies the nature of the problem and evaluates possible solutions, then possibly in collaboration with other health care professionals, chooses the best one to implement, and continues to monitor outcomes to determine the effectiveness of the solution

Problem solving for one situation contributes to the nurse’s body of knowledge that can be used for problem solving in other similar situations

Decision Making

The product of critical thinking that focuses on problem resolution

Decision making process involves: identifying the problem, assessing all options, weighing each option against a set of criteria, considering the consequences and then making a final decision

Specific Critical Thinking Competencies

These include:

Diagnostic reasoning

Clinical inference

Clinical decision making

Diagnostic Reasoning and Clinical Inference

Diagnostic reasoning – the process of determining a patient’s health status after making behavioural and physical observations and after assigning meaning to the behaviours, signs and symptoms exhibited by the patient

Clinical Inference – this is part of diagnostic reasoning and refers to the process of drawing conclusions from related pieces of evidence.

Clinical Reasoning

A cognitive process of thinking about patient issues, making inferences and deciding on the actions to be implemented in a particular clinical situation.

It is the process by which nurses collect cues, process the information, come to an understanding of a problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process.

Clinical Decision Making

Focuses on defining patient problems and selecting appropriate interventions

Distinguishes professional nurses from technical personnel

It is a judgement that includes critical and reflective thinking and action and the application of scientific and practical knowledge

Clinical Judgement

Clinical Judgement – involves “recognizing the most important aspects of a clinical situation, interpreting their meanings, and responding appropriately.” (Potter & Perry, 2019, p. 180)

How does critical thinking influence clinical judgement and clinical decision making?

Clinical Judgement – involves “recognizing the most important aspects of a clinical situation, interpreting their meanings, and responding appropriately.” (Potter & Perry, 2019, p. 180)

Clinical decision making – “focuses on defining patient problems and selecting appropriate interventions.” (Potter & Perry, 2019, p. 180)

Critical thinking is central to both these processes.

It helps to help choose the best action to meet a desired goal

The importance of Critical Thinking in Nursing

“Critical thinking is central to nursing practice because it allows you to test and refine nursing approached, learn from successes and failures, apply nursing research findings, and ensure holistic patient-centred care.” (Potter& Perry, 2019, p. 174)

“Nurses recognize that an issue exists, analyzes information about the issue, evaluates information and draws conclusions.” (Potter& Perry, 2019, p. 174)

How do nurses apply critical thinking to nursing?

In consultation with the patients, nurses consider what is important in a situation, explore alternative solutions, consider ethical principles, and then make informed decisions about how to proceed. (Potter & Perry, 2019, p.174)

Nurses apply the nursing process as a critical thinking competency by assessing , diagnosing, planning, implementing and evaluating patient care

Critical Thinking and Application

A 77-y-old male has been admitted with a COPD exacerbation.

He is currently on 2L nasal prongs with an order to titrate to maintain his oxygen saturations between 88-92%.

Assessment findings: RR = 32 and SaO2 = 86%.

Through critical thinking you realize that this is not appropriate for this patient.

What should you do first?

Critical Thinking and Application (cont’d)

Unfortunately repositioning, coughing and deep breathing do not help, so you make the decision to increase his oxygen to 4L, and monitor for a couple of minutes.

Evaluation: initially SaO2 = 90%, but drops back down to 86%.

What should the nurse do next?

Critical Thinking and Application (cont’d)

Findings: coarse crackles in his right mid and lower lobes.

Blood work from this am: WBC has increased from 12 to 18

You are now questioning if the patient has pneumonia.

The nurse identified what was important in this situation, explored alternative solutions, and then made informed decisions about how to proceed.

This is critical thinking in action!

Reflective Practice and Critical Thinking

What is reflective practice?

Why is it important for nurses?

How does reflective practice use critical thinking skills?

Concept Mapping

Technique that uses a graphic depiction of linear and nonlinear relationships to represent critical thinking

Used to develop analytical skills

Allows one to organize (and reorganize) and connect information, making meaning of the concepts

Effective method to facilitate creative, reflective, and critical thinking

3 Steps to Concept Mapping

The process of concept mapping involves three major steps:

List key concepts/terms related to the topic

Build up concepts to elaborate key concepts

Identify links between concepts

Examples of Concept Maps