Textbook of Medical-Surgical Nursing 3e

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Unit 1 Contemporary concepts in nursing

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

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? 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 Using the nursing process for concepts