Chapter 4

Theoretical Foundations
of Nursing Practice
 Nursing Domain
• What is a domain?
• In science a domain is the view or perspective
of a discipline.
• Nursing’s domain
• Identification and treatment of client’s health
care needs at all levels of health and in all
health care settings.
 Nursing Domain

• Person
• Recipient of nursing care
• Health
• Defined in different ways by client
• Environment/setting
• In which health care needs occur
• Nursing
• Creates individualized plan of care
Nursing’s Paradigm (Model)
 Types of Theories

• Grand and midrange theories

• Broad in scope
• Middle-range theories
• Have a more limited scope; address
specific concepts
 Interdisciplinary Theories

• Systems theory
• Basic human needs
• Maslow’s hierarchy of human needs
• Health-and-wellness model
• Stress and adaptation
• Developmental theories
• Psychosocial theories
 Maslow's hierarchy of needs
•
 Selected Nursing Theories

• Nightingale’s theory
• Focus on the client’s environment
• Henderson’s theory
• Focus on 14 basic needs
 Selected Nursing Theories
(cont’d)
• Orem’s theory
• Focus on self-care needs
• Leininger’s theory
• Focus on cultural care
 Nursing Process

• Steps
• Assessment
• Nursing diagnosis
• Planning
• Implementation
• Evaluation
Nursing Process
 Nursing Process (cont'd)

• Assessment
• Critical thinking approach
• When gathering data the nurse
synthesizes relevant knowledge, clinical
experience, critical thinking standards and
attitudes and standards of practice
simultaneously
• Directs assessment in meaningful and
purposeful way
 Nursing Process (cont'd)
• A critical thinker is:
• proactive: anticipates problems, not reactive
• systematic: gathers information, weighs it,
draws conclusions
• logical: bases conclusions on evidence
• persistent: finishes the job
• realistic: settles for a workable solution, not the
ideal solution
Critical Thinking and the
Nursing Process
Critical Thinking in Nursing
Practice
Chapter 15
 Critical Thinking
• An active, organized, cognitive process used to
carefully examine one’s thinking and the thinking
of others
• A critical thinker identifies and challenges
assumptions, considers what is important in a
situation, imagines and explores alternatives,
considers ethical principles, applies reason and
logic, and thus makes informed decisions
 Aspects of Critical Thinking
• Reflection
• Purposefully thinking back (recalling) a
situation to discover its meaning
• Language
• Use language precisely and clearly;
framing of one’s thoughts so message
is clear
• Intuition
• Direct understanding of a situation
w/out conscience deliberation
Levels of Critical Thinking
• Basic critical thinking
• A learner trusts that experts to have the
right answers for every problem
• Complex critical thinking
• Begins to detach from authorities, analyze
and examine alternatives more
independently
• Commitment
• Nurse anticipates the need to make
choices w/out assistance from others and
then assumes accountability for those
choices
Critical Thinking Competencies
• Scientific method
• Seeking the truth or verifying that a
set of facts agrees with reality;
research
• Problem solving
• Also involves evaluation (follow-up)
• Decision making
• End point in critical thinking, leads to
problem resolution
 Critical Thinking
Competencies
• Diagnostic reasoning and inference
• Diagnostic reasoning- process of
determining a client’s health status after
the nurse assigns meaning to behaviors,
physical s/s
• Forming nursing diagnosis
• Inference-drawing of conclusions from
related pieces of evidence
 Critical Thinking
Competencies
• Clinical decision making
• Process requires careful reasoning so that
the options for the best client outcomes are
chosen on the basis of client’s condition
and priority of problem
• Criteria to aid in making appropriate
choices
• What needs to be achieved?
• What needs to be preserved?
• What needs to be avoided?
 Nursing Process
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
 Nursing Process
• Blueprint for care
• Provides a creative, organized framework
for delivery of nursing care
• Can be used in all settings; flexible
Nursing Process
 Critical Thinking
• Components
• Knowledge base
• Experience
• Competence
• Attitudes
• Standards
Critical Thinking
Level 3- Commitment
Level 2
Complex
Level 1
Basic

Specific Knowledge Base

Experience
Competencies
Attitudes
Standards
 Attitudes
• Confidence • Perseverance
• Thinking • Creativity
independently • Curiosity
• Fairness • Integrity
• Responsibility and • Humility
accountability
• Risk taking
• Discipline
 Standards
• Intellectual
• Professional
 Intellectual Standards
• Clear • Logical
• Precise • Deep
• Specific • Broad
• Accurate • Complete
• Relevant • Significant
• Plausible • Adequate (purpose)
• Consistent • Fair
 Professional Standards
• Ethical criteria for nursing judgment
• Criteria for evaluation
• Professional responsibility
Synthesis: Critical Thinking with
Nursing Process Competency
Nursing Assessment

Chapter 16
 Assessment - Steps
• Collection and verification of data
• Analysis of data
Assessment - Approaches

• Use of a structured database format

• Gordon’s 11 Functional Health
Patterns
• Pattern of health perception and health
management
• Nutritional/metabolic pattern
• Pattern of elimination
• Pattern of exercise and activity
Assessment - Approaches
• Cognitive/Perceptional pattern
• Pattern of sleep and rest
• Pattern of self-reflection and self concept
• Relationship pattern
• Role-Sexuality-Reproductive pattern
• Pattern of coping and stress tolerance
• Pattern of values and beliefs
• Represents the interaction of the client & the
environment
 Assessment - Approaches
• Problem oriented
• Focuses on client's presenting problem
then spread out to other relevant area’s of
client’s life
Assessment – Data Collection

• Types of data
• Objective
• Subjective
• Sources of data
• Primary
• Client
Assessment – Data Collection
• Secondary
• Family and significant other
• Medical records
• Other records
• military, employment
• Literature review
• Nurse’s experience
 Assessment-
Methods of Data Collection
• Interview
• Orientation
• Working
• Termination
• Interview techniques
• Open-ended
questions
• Back channeling
• Closed ended
questions
 Assessment –
Methods of Data Collection
• Nursing health history
• Biographical information
• Reason seeking health care
• Client expectations
• Present illness or health concerns
• Health history
• Family history
 Assessment –
Methods of Data Collection
• Physical examination
• Vital signs
• Any other objective measurements
• Inspection
• Palpation
• Percussion
• Auscultation
• Olfaction
 Assessment –
Methods of Data Collection
• Diagnostic and laboratory results
• Laboratory data
• X-rays
 Assessment Process

• Nursing judgments
• Data validation and interpretation
• Data clustering
• Documentation
 Chapter 17

Nursing Diagnosis
 Nursing Diagnosis
• Definition
• A clinical judgment about individual, family,
or community responses to actual and
potential health problems or life processes
• Evolution
• Introduced 1950
• 1973 the 1st national conference held to
identify nursing functions and establish a
classification system for classification of
nursing diagnosis
 Nursing Diagnosis
• NANDA (North American Nursing Diagnosis
Association)
• Established 1982
• “To develop, refine, and promote a taxonomy of
nursing diagnosis terminology of general use for
professional nurses”
• Incorporated into ANA Standards of Nursing
Practice
• Pp. 301-302 Fundamentals text
• Critical thinking approach
• Diagnostic reasoning and judgment
 Diagnostic Process
• Analysis and interpretation of data
• Recognizing patterns or trends
• Comparing them with standards
• Coming to a reasonable conclusion
 Diagnostic Process
• Identification of client needs
• Considers all assessment data focusing on
pertinent, relevant, and abnormal data
• However, focuses on more than client’s illness or
medical diagnosis—self-care needs, psychosocial,
etc
Critical Thinking and the Nursing
Diagnostic Process
 Steps of Data Analysis

• Recognize a pattern or trend

• Examines clusters of data
• set of s/s grouped together in logical order
• Defining characteristics
• Assessment data that validates nursing
diagnosis

• Compare with standards for normal

healthful patterns
• Normal lab data
• Normal diagnostic test value
 Steps of Data Analysis
• Make a reasoned conclusion
• Defining characteristics not w/in healthy norms
isolated & form basis for problem identification
 Types of Diagnoses

• Actual
• Human responses to health
conditions/life processes that exist in
an individual, family or community
• Examples of diagnostic labels
• Acute pain
• Ineffective airway clearance
• Anxiety
 Types of Diagnoses
• Risk
• Human responses to health conditions/life
processes that may develop
• Examples of diagnostic labels
• Risk for impaired skin integrity
• Risk for infection
• Risk for powerlessenss
 Types of Diagnoses
• Wellness
• Human responses to levels of wellness in
an individual, family or community that
have a readiness for enhancement
• Examples of diagnostic labels
• Family coping: potential for growth
• Readiness for enhanced community coping
 Components

• Diagnostic label
• Name of NANDA approved nursing
diagnosis
• Related factors—etiology
• Causative or contributing factors
• 4 categories
• Pathophysiological
• Treatment-related
 Components
• Situational
• Maturational
• Phrase: “Related to”
• Identifies etiology or cause of client’s response
• Etiology
• Cause of nursing diagnosis
• Must be w/in domain of nursing that responds
to nursing interventions
 Components
• Is not same as medical diagnosis

• Ineffective airway clearance related to poor

coughing technique
• Anxiety related to social isolation secondary to
protective isolation
• Risk for infection related to indwelling Foley
catheter
 Components
• Definition
• NANDA approved definition for each diagnosis
• Risk factors that increase client vulnerability
• Environmental
• Physiological
• Psychological
• Genetic
• Chemical elements
 Components
• Support of the statement
• Nursing assessment data must support
diagnostic label
• Related to factors must support etiology
 Sources of Errors
• Data collection
• New student approach assessment in steps
• Accurate
• Complete
• Use organized approach
• Interpretation and analysis of data
• Validate subjective data with objective
physical findings as necessary
• Identify and organize relevant assessment
patterns to support present of client
problems
 Sources of Errors
• Clustering
• Avoid premature clustering of data
• Nurse makes a nursing diagnosis before all
data is grouped
• Avoid trying to make nursing diagnosis fit
s/s
• Diagnostic statement
• Use standardized nursing language
• NANDA
Avoiding and Correcting Errors

• Identify the client’s response

• Not medical diagnosis
• Identify a NANDA statement
• Rather than a symptom
• Identify a treatable etiology
• Rather than a clinical sign or chronic
problem
 Avoiding and Correcting
Errors
• Identify the problem caused by a
treatment or diagnostic study
• Rather than the treatment of study itself
• Identify the client response to
equipment
• Rather then the equipment itself
• Identify the client’s rather than the
nurse’s problems or interventions
• Patient specific
Avoiding and Correcting Errors
(cont’d)
• Identify the client’s problem rather
than the goal
• Make a professional judgment
• Rather than prejudicial judgments
• (subjective and objective data only)
• Avoid legally inadvisable
statements
• Statements that imply blame,
negligence or malpractice
Avoiding and Correcting Errors
(cont’d)
• Identify the problem and etiology
• Avoid circular statement
• Identify only one problem in the
diagnostic statement
 Chapter 18

Planning Nursing Care

 Planning

• Planning
• Client centered goals and expected
outcomes are established
• Nursing interventions are selected
 Planning
• Establishing priorities
• Ranking nursing diagnosis in order of
importance
• Determining client-centered goals and
outcomes
• Selecting nursing interventions
 Planning (cont'd)
• Priorities
• High
• Maintaining adequate oxygenation
• Safety
• Providing comfort
• Can be psychological
• Intermediate
• Non-emergent, non-life threatening
• Low
• Long-term health care needs, education
 Planning (cont'd)

• Goals-Guidelines
• Client centered
• specific and measurable behavior or
response that reflects a clients' highest
possible level of wellness and functioning
• “Client will remain free from infection”
• Partner with client during goal setting
• Ensures adherence to plan of care
 Planning (cont'd)
• Time limited
• Goals should not only meet immediate needs
but strive toward prevention and rehabilitation
• Short term
• Usually less than a week
• “Client will achieve comfort within 24 hours”
• Long term
• Usually over weeks or months
• “Client will adhere to post-operative activity
restrictions for 1 month”
 Outcomes
• Specific measurable change in a client’s
status that is expected to occur in response
to nursing care
• Measurable
• “Client will report pain acuity less than 4 on a
scale of 0 to 10”
 Outcomes

• Progressive steps
• Provide direction for selection and
use of nursing interventions
• Linked to goals and nursing
diagnoses
• Objective criteria for evaluating
effectiveness of nursing interventions
 Goals and Outcomes

• Guidelines
• Client centered
• Reflect client behavior, not nurse’s
• “Client will ambulate in the hall 3 times
a day” not “Ambulate in hall 3 times a
day”
• Singular
• Each goal or outcome should only
address ONE behavior or response
• Observable
• Observable changes
 Goals and Outcomes
• Measurable
• Use terms describing quantity, quality,
frequency, length, or weight
• Do not use terms such as: normal, stable,
sufficient
• Time limited
• Short or long term, given time in hours/days
 Goals and Outcomes
• Mutual
• Client and nurse agree upon
• Realistic
• Setting goals that are achievable
 Combining Goal and Outcome
Statements
• “Client will achieve pain control as
evidence by reporting pain acuity less than a
4 on a scale of 0 to 10 within 48 hours”
• Goal portion of statement provides a broad
description of desired client status
• Achieving pain control
• Outcome portion contains the observable
criteria needed to measure success
• 4 on a pain scale
 Nursing Interventions

• Types
• Nurse initiated
• Independent response of nurse to
client’s health care needs and nursing
diagnosis
• Nurse is able to work within his/her
scope of practice on client’s behalf
• Based on scientific rationale (EBP)
• Do not require a physician’s order
Nursing Interventions (cont'd)
• Physician initiated
• Manage a medical diagnosis
• Physicians written orders
• Standing orders
• Treatment protocols
• Individual written orders
• Collaborative
• Multiple health care professionals
• Nursing
• Therapy (occupational, physical, speech)
• Nutritionist
Nursing Interventions (cont'd)

• Selection criteria
• Characteristics of nursing diagnosis
• Interventions must be directed toward
altering etiological (related to) factors
• When an etiological factor can’t
change, intervention directed toward
treating s/s
• Risk for diagnosis, interventions aimed
at altering or eliminating the risk factors
for diagnosis
Nursing Interventions (cont'd)
• Expected outcomes
• Specified before selecting intervention
• Stated in terms used to evaluate effectiveness
of intervention
• Research base
• Supports nursing intervention (EBP)
• When research not available, use scientific
principles or consult clinical expert
Nursing Interventions (cont'd)
• Feasibility
• Specific intervention may have potential for
interacting with other interventions chosen by
nurse
• Nurse must be knowledgeable of total plan of
care
• Consider: will intervention be clinically effective
and cost efficient?
• Consider: are time and personal available?
• Acceptability to the client
• Intervention must be acceptable to client/family
• Client must make informed decision
Nursing Interventions (cont'd)
• Nurse competencies
• Nurse must be able to carry out interventions
• Nurse must be knowledgeable of scientific
rationale for intervention
• Nurse must possess the necessary
psychosocial and psychomotor skills to
complete intervention
• Nurse must be able to function w/in particular
setting to effectively utilize health care
resources
 Care Plans

• Guide for clinical care

• Serves as a document to
communicate a client’s nursing care
to all members of health care team
 Care Plans
• Student
• Institution
• Kardex
• Computerized
• Community-based settings
• Critical pathways
• Allows staff from all disciplines to develop
integrate car plan
• Concept maps
• Diagram of client problems and interventions;
shows relationships to one another
Critical Thinking and the Process of
Planning
Concept Map: Nursing and Medical
Diagnosis
Concept Map Data to Support
Nursing Diagnoses.
Concept Map Relationships
Between Nursing Diagnoses
 Chapter 19

Implementing Nursing Care

 Implementation

• Begins after care plan has been developed

• Nursing Intervention
• Any treatment , based upon clinical
judgment and knowledge, that a nurse
performs to enhance client outcomes
 Types of Nursing Interventions
• Nurse initiated, physician initiated, collaborative
• Direct
• Treatments performed through interaction with client
• IV therapy, med administration
• Indirect
• Treatments perform away from client but on behalf of
client or groups of clients
• Infection control, documentation
 Types of Nursing Interventions
• Protocols
• Written plan specifying procedures to be
followed during care of clients with a select
clinical condition or situation and standing
orders
• Ex.: Post-op
 Types of Nursing Interventions
• Standing Order
• Pre-printed document with orders for routine
therapies, monitoring guidelines and/or
diagnostic procedures for specific clients with
identified clinical problems
• Ex.: ICU
• Must be approved and signed by prescribing
MD before implementation
Choosing Nursing Interventions

• Critical thinking and selection of

nursing interventions (6 factors)
• Nursing diagnosis
• Altering etiological factors
• Expected outcomes
• Criteria used to judge interventions success
• Evidence based
• Research, proven practice guidelines
Choosing Nursing Interventions
• Feasibility
• How will proposed intervention affect other planned
interventions?
• Acceptability (to the client)
• Summarize for client
• Informed decision making
• Nurse competencies
• Nurse must be competent to perform the
intervention
Critical Thinking and the Process
of Implementing Care
 Implementation Process

• Reassessing the client

• Partial assessment may focus on one
dimension of the client
• Determines whether proposed intervention
is still appropriate
• See cast study
 Implementation Process
• Reviewing and revising the existing care
plan
• If there has been a change in client status and
the nursing diagnosis & related intervention are
no longer appropriate, care plan needs to be
revised
 Modification of Care Plan:
4 Steps
• Data in assessment column revised to reflect
client’s current status
• Revise nursing diagnosis
• Delete non-relevant nursing diagnosis
• Add new nursing diagnosis
• Revise related factors
• Revised specific interventions so they corresponds
to new nursing diagnosis and client goals
• Determine evaluation methods/outcomes
• See case study
Implementation Process (cont'd)

• Organizing resources and care delivery

• Equipment
• Personnel
• Environment
• Client
• Anticipating and preventing complications
• Identifying areas of assistance
 Implementation Skills

• Cognitive skills
• Interpersonal skills
• Psychomotor skills
 Direct Care Measures

• Activities of daily living (ADLs)

• Instrumental activities of daily living
• Physical care techniques
• Counseling
• Teaching
• Controlling for adverse reactions
• Preventive measures
 Indirect Care Measures

• Communicating nursing interventions

• Delegating, supervising, and evaluating the
work of other staff members
Chapter 20

Evaluation
 Evaluation
• Final step of nursing process
• Is crucial to determine whether the client’s
condition or well-being improves
• Nurse compares client behavior and
responses assessed before nursing
intervention with behaviors and responses
after administering nursing care
 Evaluation
• Positive evaluation
• Desired results are met
• Lead nurse to conclude nursing interventions
were effective
• Negative evaluation
• Client’s inability to meet expected outcomes
• Indicate interventions are not effective in
minimizing or resolving actual problem
 Evaluation Process

• Identifying evaluative criteria and standards

• Goals
• Specifies expected behavior or responses
• Expected outcomes
• Expected measurable results
• Statements of progressive, step by step responses or
behaviors that a client needs to accomplish to achieve
goals of care
• Collecting data to determine if criteria or
standards are met
• Primary source of evaluation data
• Client
 Evaluation Process
• Interpreting and summarizing findings
• Compares expected and actual findings
• Documenting findings
• Objective
• Subjective
• Terminating, continuing, or revising the care plan
• Goal is met
• That portion of care plan is discontinued
• Unmet or partially unmet goals
• Continue and revise care plan
 Success of Goals

• Examine the goal statement

• Assess the client
• Compare the outcome with client
behavior or response
• Judge the degree of agreement between
outcome and client response
• Determine reasons for no agreement or
partial agreement
 Care Plan Revisions
• Discontinuing
• Outcomes are met successfully, care plan
documented as discontinued
• Modifying
• Reassessment
• Ensures database is accurate and current
• Nursing diagnosis
• Determine if current nursing diagnosis are accurate
• Revise/new diagnosis
• Client goals and outcomes
• Revise if unrealistic or inappropriate
• Nursing interventions
• If unsuitable either revise or discontinue
 Quality Improvement
• Approach—purpose
• All health care professionals are responsible for
evaluating their practices, incorporating EBP
into care, and to measuring success of meeting
client outcomes
• Outcome management
• “Managing individual client outcomes of clients
as a result of prescribed treatments”
• Professional outcomes
• Measures of professional caregiver’s performance
• Client outcomes
• Measures of client’s status after receiving care
Example of a Goal, Outcome, and
Evaluative Measure

• Goal: client’s pressure ulcer will heal within

7 days
• Outcome: erythema will be reduced in 2
days
• Evaluative measure: inspect color,
condition, and location of pressure ulcer
 Chapter 21
Managing Client Care
Building a Nursing Team

• An empowered nursing team begins with

the nurse executive.
• The nurse executive, nurse manager, and
staff nurse work collaboratively to create
an empowering work environment.
Nursing Care Delivery Models
Team nursing: Total client care:
Team members provide The RN works directly
care under the with the client.
supervision of an RN.

Primary nursing: Case management:

RN assumes a caseload RN maintains
of clients during their responsibility for client
entire stay. care from admission to
discharge.
Decentralized Decision Making
• Occurs at the unit level
• Includes responsibility, autonomy, authority,
and accountability
• Staff involvement:
• Shared governance
• Nurse-physician collaborative practice
• Interdisciplinary collaboration
• Communication
• Education
 Leadership Skills for Nursing
Students
Clinical decision Priority setting
making

Organizational skills Use of resources

Time management Evaluation

Team communication Delegation