Introduction to Medical-Surgical

Nursing

Sasha A. Rarang, MSN, CCN, RN

What is Medical-Surgical NursingMedical-surgical nursing is the foundation of all

nursing practice.

Once upon a time and not so very long ago, all nurses practiced the art and science of nursing on wards, everyone was a medical or surgical nurse - that is where all nursing started.

Today many nurses choose to work in the specialty of medical-surgical nursing.

Medical-surgical nursing has evolved from an entry-level position to an adult health specialty.

(Academy of Medical-Surgical Nursing, 2011)

What is Medical-Surgical NursingMedical-Surgical Nursing - is no longer viewed as

stepping-stone but is solid rock and the backbone of every institution.

It is the largest group of practicing professionals.

Medical-surgical nurses care for adult patients in many settings, such as inpatient care unit, clinics, HMOs, ambulatory care units, home health care, long-term care, skilled nursing homes, urgent care centers, surgical centers, and universities, just to name a few.

(Academy of Medical-Surgical Nursing, 2011)

What is Medical-Surgical NursingMedical-Surgical Nurses

A. Have a Vast Set of Skills

Are knowledgeable in all aspects of adult health.

Have excellent assessment, technical, organizational, and prioritization skills.

Teach patients, families, peers, and other health professionals.

(Academy of Medical-Surgical Nursing, 2011)

What is Medical-Surgical NursingB. Are Advocates for Patients

Understand the importance of measuring and improving the quality of care delivered

Consider patient safety to be the top priority

Support patients in their efforts to identify what is in their best interests.

(Academy of Medical-Surgical Nursing, 2011)

What is Medical-Surgical NursingC. Welcome Diversity

Care for patients of all ages

Manage the care of patients with multiple medical, surgical, and/or psychiatric diagnoses

Manage the care of patients with diagnoses across all medical specialties

Celebrate that there is always something new to learn

Can practice in hospitals, clinics, outpatient surgery centers, MD offices, long-term care facilities, and other practice sites

What is Medical-Surgical NursingD. Make a Difference in People's Lives Every Day

Provide comfort and attention to people who, at that moment, need someone to take an interest in their lives

Heal patients physically and emotionally through intuitive experiences that rely on observation and touch.

Assist patients in returning to their highest level of functioning

Provide dignity and respect in end-of-life decision-making and care

What is Medical-Surgical NursingE. Are the Backbone of Every Adult-Care Clinical Agency

All adult patients are eventually cared for by medical-surgical nurses

(Academy of Medical-Surgical Nursing, 2011)

Summary of Medical-Surgical Nurse Role

1. Provider of Care

2. Manager of Care

3. Member of the Profession

Activities of the MS NurseCaregiver

Educator

Communicator

Leader

Manager

Researcher

Critical ThinkingRelationship between

Critical Thinking and Nursing Process

What is critical thinking in nursing

Critical thinking in nursing is an active, organized, cognitive process use to scrutinized one’s thinking and the thinking of others by application of knowledge and experience, problem solving, and decision making resulting in a nursing.

Medical Surgical nurse must be able to correctly identify problems and implement the best solutions (interventions).

Critical thinking incorporates reflection, language, and intuition, and it involves through three distinct levels as the nurse gains knowledge and experience while maturing into a competent nursing professional.

What is Critical Thinking

Active, organized, cognitive process used to carefully examine one’s thinking and the thinking of others

It involves the use of the mind in forming conclusions, making decisions, drawing inferences, and reflecting

Components of Critical Thinking

Knowledge

Experience

Critical Thinking competencies

Attitudes

Intellect

Professional Standards

Critical Thinking and Nursing Judgment

How do we make decisions?

How do nurses make decisions about patient care?

What do we rely on to help us in decision making?

Critical Thinking and Nursing Judgment

Not a linear step by step process

Process acquired through hard work, commitment, and an active curiosity toward learning

Decision making is the skill that separates the professional nurse from technical or ancillary staff

Critical Thinking and Nursing Judgment

Good problem solving skills

Not always a clear textbook answer

Nurse must learn to question, look at alternatives

How do nurse's accomplish Critical Thinking ?

Learns to be flexible in clinical decision making

Reflect on past experiences and previous knowledge

Listen to others point of view

Identify the nature of the problem

Select the best solution for improving client’s health

Critical Thinking in NursingPurposeful, outcome-directed

Driven by patient, family, and community needs

Based on principles of nursing process and the scientific method

Requires specific knowledge, skills, and experience

New nurses must question

Critical Thinking in NursingGuided by professional standards and ethic codes

Requires strategies that maximize potential and compensate for problems

Constantly reevaluating, self-correcting, and striving to improve

Formula for Critical ThinkingStart Thinking

Why Ask Why

Ask the Right Questions

Are you an expert?

Aspects of Critical ThinkingReflection

Language

Intuition

Levels of Critical ThinkingBasic

Complex

Commitment

Critical Thinking Competencies

Scientific method

Problem Solving

Decision Making

Diagnostic Reasoning and Inferences

Clinical Decision Making

Nursing Process

Nursing ProcessSystematic approach that is used by all nurses to

gather data, critically examine and analyze the data, identify client responses, design outcomes, take appropriate action, then evaluate the effectiveness of action

Involves the use of critical thinking skills

Common language for nurses to “think through” clinical problems

Nursing Process

The Nursing Process Critical Thinking Skills

Assessment – Identify human responses to health and illness

ObserveDiffrentiate between relevant and irrelevant data between important and unimportnatOrganize, categorize, and validate data.

Diagnosing – Analyze and interpret assessment data

Identify clusters and cuesDetect InferencesRecognize the problemDefer from making judgments

Planning – Determine the best approach to address and resolve the client’s health problem(s)

Make generalizationTake knowledge and apply to more than one situationCreate outcome criteriaTheorize

Implementation – from conclusions make decisions, and draw inferences about the care plan.

Use knowledge baseTest theories.

Evaluation – interpret evaluative findings to judge both the client’s current health status and whether or not outcome were achieved.

Determine accuracy of theoriesEvaluate based on outcome criteria

Attitude or Mindset that affects how nurse approaches a problem

Confidence – feel sure of abilities.

Independence – analyze ideas for logical reasoning.

Fairness – is objective, non-judgmental.

Responsibility – Practices according to standards of practice.

Risk Taking – takes calculated chances in finding better solutions to problems.

Discipline- develops a systematic approach to thinking.

Perseverance , Creativity, Curiosity, Integrity & Humility.

Thinking and LearningLifelong process

Flexible, open process

Learn to think and to ANTICIPATE

What, why, how questions

Look beyond the obvious

Reflect on past experience

New knowledge challenges the traditional way

Components Of Critical Thinking

Standards

Ethical criteria for Nursing judgment- Code of Ethics

Criteria for evaluation- Standards of care

Standards of professional responsibility that nurses strive to achieve are cited in Nurse Practice Acts, JCAHO guidelines, institutional policy and procedure, ANA Standards of Professional Practice

Nursing judgment based on ethical criteria.

Evaluation that relies on evidence-based-practice

Demonstration of professional responsibility.

Critical Thinking SynthesisReasoning process by which individuals reflect on and

analyze their own thoughts, actions, & decisions and those of others

Not a step by step process

Critical Thinking Case StudyMrs. Lutz is a 78 yearr old woman who has undergone

radiation therapy and three surgeries for cancer. She is not responding well, cannot eat, and is losing weight. The physician has decided to place a subclavian catheter to administer total parenteral nutrition. The nurse takes the informed consent form to the patient to sign and explains to her that “the doctor will place a small tube in your vein to give you more nutrients to help you regain your strength and heal”. Mrs. Lutz says, “I’m so tired of all this pain. I’m not sure I want anything else done, and I surely don’t want to be hurt again.

Case Study QuestionsWhat factors does the nurse need to assess that might

affect Mrs. Lutz’s ability to consent?

Before she signs the consent form, how can the nurse be certain that her consent was truly “informed”?

Case Study ContinuedThe nurse replies to Mrs. Lutz: “Now, now, your doctor

has ordered this to make you well. Don’t worry, we’ll make sure you don’t feel a thing. Your doctor will be here soon and he will expect this consent to be signed. Won’t you please sign it now?”

Case Study QuestionsEvaluate the nurse’s approach to Mrs. Lutz in regard to

the invasive procedure. What do you think about it and why?

Nursing ProcessTraditional critical thinking competency

5 Step circular, ongoing process

Continuous until clients health is improved, restored or maintained

Must involve assessment and changes in condition

When using the Nursing Process

Identify health care needs

Determine Priorities

Establish goals & expected outcomes

Provide appropriate interventions

Evaluate effectiveness

AssessmentSystemically collects, verifies, analyzes and

communicates data

Two step process- Collection and Verification of data & Analysis of data

Establishes a data base about client needs, health problems, responses, related experiences, health practices, values. lifestyle, & expectations

Assessment DataSubjective Data

Objective Data

Sources of Data

Methods of Data Collection-Interview

Interview initiates nurse-client relationship

Use open-ended questions

Nursing health history

Nursing DiagnosisStatement that describes the client’s actual or potential

response to a health problem

Focuses on client-centered problems

First introduced in the 1950’s

NANDA established in 1982

Step of the nursing process that allows nurse to individualize care

Planning for Nursing Care

Planning for Nursing CareClient-centered goals and expected outcomes are

established

Priorities are set relating to unmet needs

Maslow’s Hierarchy of Needs is a useful method for setting priorities

Priorities are classifies as high, intermediate, or low

Purpose of Goals and OutcomesProvides direction for individualized nursing

interventions

Sets standards of determining the effectiveness of interventions

Indicates anticipated client behavior or response to nursing care

End point of nursing care

Goals of CareGoal: Guideposts to the selection of nursing interventions

and criteria in the evaluation of interventions

What you want to achieve with your patient and in what time frame

Short term vs. Long term

Outcome Of Care: What was actually achieved, was goal met or not met

Nursing InterventionsInterventions are selected after goals and outcomes

are determined

Actions designed to assist client in moving from the present level of health to that which is described in the goal and measured with outcome criteria

Utilizes critical thinking by applying attitudes and standards and synthesizing data

Types of InterventionsNurse-Initiated

Physician-Initiated

Collaborative Interventions

Selection Of InterventionUsing clinical decision making skills, the nurse

deliberates 6 factors:

Diagnosis, expected outcomes, research base, feasibility, acceptability to client, competency of nurse

Nursing Care PlansWritten guidelines for client care

Organized so nurse can quickly identify nursing actions to be delivered

Coordinates resources for care

Enhances the continuity of care

Organizes information for change of shift report

Implementation of Nursing Interventions

Describes a category of nursing behaviors in which the actions necessary for achieving the goals and outcomes are initiated and completed

Action taken by nurse

Types of Nursing Interventions

Standing Orders: Document containing orders for the use of routine therapies, monitoring guidelines, and/or diagnostic procedure for specific condition

Protocols: Written plan specifying the procedures to be followed during care of a client with a select clinical condition or situation (Pneumonia, MI, CVA)

Implementation Process involves:

Reassessing the client

Reviewing and revising the existing care plan

Organizing resources and care delivery (equipment, personnel, environment)

EvaluationStep of the nursing process that measures the client’s

response to nursing actions and the client’s progress toward achieving goals

Data collected on an on-going basis

Supports the basis of the usefulness and effectiveness of nursing practice

Involves measurement of Quality of Care

Evaluation of Goal Achievement

Measures and Sources: Assessment skills and techniques

As goals are evaluated, adjustments of the care plan are made

If the goal was met, that part of the care plan is discontinued

Redefines priorities

Evidence-Based Practice in Medical-Surgical Nursing.

Implementing Evidence-Based Practice in Nursing

Evidence-Based Practice (EBP) – deliberate se of current best evidence to make decisions about patient care.

Considers preferences and values as well as one’s own clinical expertise.

Evidence-based practice (EBP) in nursing is using and carrying out nursing practices based on the best available knowledge.

Evidence-Based PracticeEvidence-based practice is a way for nurses to

examine nursing practices, analyze alternative and contradictory data, and make sound nursing care decisions supported by the best available research evidence.

This systematic approach to nursing practice enhances the likelihood that patients will receive the best nursing care possible

Critical Thinking is an essential tool for EBP Process to provide quality, cost-effective, safe-patient care.

The best source of scientific evidence is research.

Evidence-Based Practice Nursing

Steps in conducting EBP.

First, information will be presented about asking the clinical question in a way that will give the most relevant evidence.

Next, you will be guided through finding the most relevant evidence from the latest clinical practice guidelines or systematic reviews.

After gathering the evidence you will learn how to evaluate the validity, relevance, and applicability to the clinical situation.

Then you will use and apply critical thinking and appraisal skills to make a clinical decision that is based on integration of the gathered evidence with what you, the nurse, know about the situation at hand. This decision will also incorporate an understanding of available resources and the patient’s preferences and values.

Care and Comfort

Caring in Nursing PracticeCaring is central to nursing practice.

Caring is a universal phenomenon influencing the ways in which people think, feel, and behave in relation to one another.

Caring determine what matters to a person, it describes a wide range of involvement.

Clients perception of caring :

Caring emphasizes what clients expects from their

caregivers.

Client’s Perception of Caring

Client’s value the nurses effectiveness in performing tasks and affective dimension of nursing care.

What client’s perception is important because health care is lacing greater emphasis on client satisfaction.

Caring is a moral imperative.

Caring in Nursing Practice Caring is a product of of person’s culture, values, experiences,

and relationships with others.

Nursing behaviors related to caring inlcude:

Providing presence – being there and being with.

Touch – comforting approach. Task-oriented touch

caring touch

protective touch.

Listening

Knowing the client

Spiritual Caring

Leadership in the Medical- Surgical Setting

The leadership role of medical-surgical nurses: what is it?

Health care providers are called to promote health care that is safe, effective, client-centered, timely, efficient, and equitable (Institute of Medicine, 2001).

At the same time, evidence-based practice initiatives, new quality improvement approaches, and informatics and technology advances are imposed on nurses in the workplace (Institute of Medicine, 2003).

These challenges present some pretty tall mountains for nurses to climb. However, strongly medical-surgical nurses can address these challenges in the microsystem by assuming a leadership role in the workplace.

Leadership Role for Medical-Surgical Nurse

Leadership role emerge from the nurse's professional commitment to quality patient care and a work environment that fosters excellence in practice.

Medical-surgical nurses and their employers would recognize the nurses' knowledge as expert caregivers, and these medical-surgical nurse's would be willing to act to change nursing care and/or the environment to improve patient outcomes.

Some examples: A medical-surgical nurse would volunteer to facilitate the implementation of an evidence-based practice project that examines the evidence for decubitus ulcer management.

Another medical-surgical nurse would take the lead on a project to assess the root of medication errors on the unit.

patient care and their responsibility as professional nurses.

Leadership in MS Nursing A nurse with an interest in informatics would be the

unit "cheerleader" and facilitator in implementing new software technology on the unit.

These medical-surgical nurse leaders would also be aware of issues that arise related to patient care and would initiate changes in care to address those issues.

Medical-surgical nurses would recognize the need for change and lead specific initiatives to integrate change into the workplace. These nurses would be willing to tackle a project because of their commitment to quality

Leadership In MS Nursing The scope of medical-surgical nurse leadership

role is local, at the unit level, and more focused. This role is founded on the expert knowledge that medical-surgical nurses have. It is grounded in professional responsibility, and it is supported by skills in group facilitation and critical thinking.

Assuming a leadership role on the unit may seem like an overwhelming task. However, medical-surgical nurses have the basic skills to move into roles that facilitate change and improve patient care.