Textbook of Medical-Surgical Nursing 3e

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Chapter 2   Thoughtful practice

ultimately leads to appropriate and effective actions that meet a person’s specifically identified need. Thoughtful practice requires all the components working in synchronicity for the benefit of the persons within the thera- peutic relationship. The following section discusses the actions of nurses as thoughtful professionals. CLINICAL REASONING CHALLENGE An 84-year-old man who is originally from Vietnam is hospitalised in the neurosurgical intensive care unit with a cerebrovascular accident (CVA, stroke). His immediate family members insist on staying with him around the clock, and many extended family members visit each day, staying late into the night. His prognosis is poor, and when his attending doctor discusses discontinuing his life support therapy with his family members who are his legal next of kin, they acquiesce but request that all family members be allowed to remain present to witness his death. Policies in the intensive care unit do not permit more than three family members to be with a patient at any given time. The staff members complain that they have difficulty complet- ing their tasks with other critically ill patients because of the distractions they face from the multiple family mem- bers visiting this man. How can you help the nursing staff explore the meaning of the family’s behaviour and under- stand their own negative feelings about this behaviour? Devise a strategy that will help resolve this situation. Clinicians’ actions Decision making, like peoples’ beliefs and values, is often not overtly expressed but is evident in the behaviour or the action of the clinician. An action taken by a clinician is simply defined as ‘the behaviour following on from a judgement or decision’ (Thompson & Dowding, 2002, p. 14). This action may be a simple act or a series of actions, it may involve undertaking a practical task or communicating with another clinician. Actions resemble clinical reasoning as they are also dependent on the confidence and competence of the clinician and the assessment of the risk involved (Levett-Jones et al., 2010). Decisions include when the action will be undertaken. This is often referred to as ‘patient prioritisation’ and is a skill that is enhanced by experience. When there are time pres- sures, the quality of the decision and hence the action may be affected. This is a very important consideration in modern healthcare as time is seen to be inadequate in most clinical settings (Beckett, Gilbertson & Greenwood, 2007). Although the actions taken following a judgement and decision can be diverse and complicated they are not disorganised or unstruc- tured. The actions can be described through an organised series of actions called the processes of care that are described in the following section. Person-centred process of care The next component of thoughtful practice, as shown in Figure 2-1, is the series of actions known as the processes of care. Although each care encounter, or clinical situation, is differ- ent, clinicians need a structured approach to developing these

processes. It is in the processes of care that the skills in clinical reasoning and judgement are enacted in a person-centred way, through the nursing process, a systematic approach to a series of actions that meet the needs of the person while preserving their humanity. The nursing process The nursing process is a deliberate problem-solving approach for meeting a person’s healthcare and nursing needs. Although the steps of the nursing process have been stated in various ways by different writers, the common components cited are assessment, diagnosis, planning, implementation, and eval- uation. These original components can be further enhanced to include nursing diagnoses and collaborative problems as part of assessment and outcome identification as a part of planning. Therefore for the purpose of this text, although based on the traditional five steps, the sequences of steps for the nursing process: assessment, diagnosis, outcome identifi- cation, planning, implementation, and evaluation are defined as follows:  1. Assessment: The systematic collection of data to determine the patient’s health status and identify any actual or potential health problems. (Analysis of data is included as part of the assessment. For those who wish to emphasise its importance, analysis may be identified as a separate step of the nursing process.)  2. Diagnosis: Identification of the following two types of patient problems: (a) Nursing diagnoses: Actual or potential health problems that can be managed by independent nursing interventions (b) Collaborative problems: ‘Certain physiological  3. Planning: Development of goals and outcomes, as well as a plan of care designed to assist the patient in resolving the diagnosed problems and achieving the identified goals and desired outcomes.  4. Implementation: Actualisation of the plan of care through nursing interventions.  5. Evaluation: Determination of the patient’s responses to the nursing interventions and the extent to which the planned outcomes have been achieved. Dividing the nursing process into distinct steps serves to emphasise the essential nursing actions that must be taken to resolve the patient’s nursing diagnoses and manage any collab- orative problems or complications. Dividing the process into separate steps is, however, artificial: the process functions as an integrated whole, with the steps interrelated, interdependent, and recurrent (Figure 2-4). Chart 2-7 presents an overview of the nursing activities involved in applying the nursing process. Using the nursing process for a period of care Assessment Assessment data are gathered through the health history and the physical assessment. In addition, ongoing monitoring is crucial to remain aware of changing patient needs and the effectiveness of the nursing care. complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using doctor-prescribed and nursing-prescribed interventions to minimise the complications of the events’ (Carpenito, 2012)