34
Unit 1
Contemporary concepts in nursing
that occur by commission or omission are now measured and
studied using such techniques as critical incident analysis to
determine if there is an error in the system that may be recti-
fied (Healy, 2011).
When care focuses on tasks or a system fails to optimise
opportunities to promote person-centredness and values the
tasks or the system rather than the person, it can lead to ritual
behaviour and robotic care where clinicians become discon-
nected and disengaged. This in turn contributes to failure
to rescue. Although adverse outcomes do occur in nursing,
considerable effort is being undertaken through initiatives
such as practice development and other means of examin-
ing practice for the purpose of learning from and improving
practice. However, when clinicians are skilled, committed and
enthusiastic, the therapeutic relationship carries over into the
care processes.
CLINICAL REASONING CHALLENGE
You are caring for a patient with another nursing student.
He discloses to you that he did not follow the correct pro-
cedure and has now administered the wrong medication to
the patient but is afraid to notify the faculty and nurses. He
says he did this as he observed the nurses in this clinical
area not applying all steps in the checking process. The
patient was given an antihypertensive agent that was not
due for another 12 hours. The patient appears to be ‘OK’ at
this time, and it is 2 hours since the medication was given.
What actions should be taken? Should this information
be communicated to your faculty supervisor? What is the
care priority for the patient? What evidence supports or
does not support disclosure of medication administration
errors to patients? What steps would you take and in what
order?
Using the nursing process for
concepts
Due to the expansive scope of medical surgical nursing that is
covered in this text, the nursing process has been contracted
into nursing consideration sections for specific clinical condi-
tions that follows an abbreviated form of the nursing process.
Each nursing consideration section covers assessment and
nursing interventions for that condition that are based on the
nursing diagnoses (contained in the headings), the goals and
the expected patient outcomes that reflect the evaluation part
of the nursing process. Using the information in this chapter,
the steps of nursing process can be re-expanded at will for each
clinical condition.
Applying the nursing process to periods of care for indi-
vidual patients has been described; however, nursing roles are
often diverse and complex and may require consideration of
many concepts if they are to be person-centred and holistic.
The nurse may also be caring for communities as well as
individuals, therefore the nursing process may also be used to
introduce wider concepts into actual care.
Health education
One of the most important functions of a nurse in providing
person-centred holistic care is to assist the patient, their family
and sometimes an entire community to understand their
outcomes and to monitor and manage potential complications.
Such interdependent functioning is just that—interdependent.
Requests or orders from other healthcare team members should
not be followed automatically but should be assessed critically
and questioned when necessary. The implementation phase
of the nursing process ends when the interventions have been
completed by the nurse or the patient.
Evaluation
Although occurring throughout the whole nursing process,
evaluation
(the final step of the nursing process) allows the
nurse to determine the patient’s response to the nursing inter-
ventions and the extent to which the objectives have been
achieved, that is, what is the outcome. The plan of nursing
care is the basis for evaluation. The nursing diagnoses, collabo-
rative problems, priorities, nursing interventions, and expected
outcomes provide the specific guidelines that dictate the focus
of the evaluation. Through evaluation, the nurse can answer
the following questions:
•
Were the nursing diagnoses and collaborative problems
accurate?
•
Were the patient’s and the nurse’s expected outcomes
achieved within the critical time periods?
•
Have the collaborative problems been resolved?
•
Have the patient’s nursing needs been met?
•
Should the nursing interventions be continued, revised,
or discontinued?
•
Have new problems evolved for which nursing
interventions have not been planned or implemented?
•
What factors influenced the achievement or lack of
achievement of the objectives?
•
Do priorities need to be reassigned?
•
Should changes be made in the expected outcomes and
outcome criteria?
Objective data that provide answers to these questions are
collected from all available sources (e.g. patient, family, sig-
nificant others and healthcare team members). These data are
included in the patient’s health record and must be substanti-
ated by direct observation of the patient before the outcomes
are documented. Chart 2-8 demonstrates the nursing process
for an actual period of care for a particular patient.
Unfortunately, not all the results of patient interventions
demonstrate quality care (Healy, 2011). The acuity of patients
in hospitals has increased and their care has correspondingly
become more complicated (Duffield et al., 2007). Despite the
systematic approach of the nursing process, there are times in
clinical practice when clinical reasoning and judgement fail,
errors are made and the deteriorating patient is not detected.
Failure to rescue
In the seminal study of adverse events in healthcare in
Australia, Wilson et al. (1995) identified that 57% of errors
relate to faulty reasoning processes. This lack of recognition of
the deteriorating patient is frequently called a ‘failure to rescue’
where a deteriorating situation, a problem, is not recognised or
not responded to appropriately by a clinician (Duffield et al.,
2007; Thompson et al., 2008). This may create circumstances
where there is a potential for errors to be made through not
recognising that a problem is occurring. This might lead
to incorrect decisions or actions by the clinician, and the
outcome of care may be an adverse event, which may have
affected the health or well-being of the patient. These events
