Nursing process: A look at the nursing process

Focus Topic: Nursing process

One of the most significant advances in nursing has been the development and acceptance of the nursing process. This problem-solving approach to nursing care offers a structure for applying your knowledge and skills in an organized, goal-oriented manner. Closely related to the scientific method, it serves as the cornerstone of clinical nursing by providing a systematic method for determining the patient’s health problems, devising a care plan to address those problems, implementing the plan, and evaluating the plan’s effectiveness.

Five alive

The five phases of the nursing process are dynamic and flexible. Because they’re interrelated, they often overlap. Together, they resemble the steps that many other professions rely on to identify and correct problems. They include:

  1. assessment
  2. nursing diagnosis
  3. planning
  4. implementation
  5. evaluation

Process pluses

When used effectively, the nursing process offers several important advantages:

  • The patient’s specific health problems, not the disease, become the focus of health care. This emphasis promotes the patient’s participation and encourages his independence and compliance — factors important to a positive outcome.
  • Identifying a patient’s health problems improves communication by providing nurses who care for the patient with a common list of recognized problems.
  • The nursing process provides a consistent and orderly professional structure. It promotes accountability for nursing activities based on evaluation and, in so doing, leads to quality improvement.

Nursing process: Assessment

Focus Topic: Nursing process

Assessment involves data collection used to identify a patient’s actual and potential health needs. According to American Nurses Association guidelines, data should accurately reflect the patient’s life experiences and his patterns of living. To accomplish this, you must assume an objective and nonjudgmental approach when gathering data. You can obtain data through a health history, a physical assessment, and a review of pertinent laboratory and medical information.

Health history

A health history is used to gather subjective data about the patient and explore past and present problems. First, ask the patient about his general physical and emotional health; then ask him about specific body systems and structures. Information may come from the patient himself, from the patient’s significant other or caregiver, or from other health care professionals.

The accuracy and completeness of your patient’s answers largely depend on your skill as an interviewer. Before you start asking questions, review the communication guidelines in the following sections.

Effective techniques

To obtain the most benefit from a health history interview, try to ensure that the patient feels comfortable and respected and understands that he can trust you. Use effective interview techniques to help the patient identify resources and improve problem-solving abilities. Remember, however, that successful techniques in one situation may not be effective in another. Your attitude and the patient’s interpretation of your questions can vary. In general, you should:

  • allow the patient time to think and reflect
  • encourage the patient to talk
  • encourage the patient to describe a particular experience
  • indicate that you have listened to the patient such as through paraphrasing the patient’s response.

Know right from wrong

Although there are many right ways to communicate with a patient, there are also some wrong ways that can hamper your interview. ( See Interview techniques to avoid.)

Conducting the interview

Physical surroundings, psychological atmosphere, interview structure, and questioning style can all affect the interview flow and outcome; so can your ability to adopt a communication style to fit each patient’s needs and situation. Close the door to help prevent interruptions and try to arrange yourself so you’re facing the patient, slightly offset from him, to create a friendly feeling. Sit down, if possible, to communicate your willingness to spend time listening to him.

Interview techniques to avoid

Nursing process

 

Start at the very beginning

Begin by introducing yourself. Establish an assessment time frame and ask if the patient has questions about the assessment procedure. Spend a few minutes chatting informally before beginning the interview.

A note on notes

You’ll need to take some notes so that you can accurately remember what the patient tells you, but make sure your note taking doesn’t interfere with your communication. If you need to document your findings during the interview using a handheld device or computer terminal, make sure your back isn’t toward the patient. Making eye contact and nodding to indicate understanding are cues that will assure the patient that you are listening to him.

Short and sweet

A patient who’s ill, experiencing pain, or sedated may have difficulty completing the health history. In such instances, obtain only the information pertaining to the immediate problem. To avoid tiring a seriously ill patient, obtain the history in several sessions or ask a close relative or friend to supply essential information.

Two types

Typically, the health history includes two types of questions: open-ended, which permit more subtle and flexible responses, and closed-ended, which require only a yes-or-no response. Open-ended questions usually result in the most useful information and give patients the feeling that they’re actively participating in and have some control over the interview. Closed-ended questions help eliminate rambling conversations. They’re also useful when the interview requires brevity — for example, when a patient reports extreme pain or digresses frequently.

Logical and patient

Whatever question type you use, move logically from one history section to the next. Also allow the patient to concentrate and give complete information on a subject before moving on.

Obtaining health history data

The health history has five major sections: biographic data, health and illness patterns, health promotion and protection patterns, role and relationship patterns, and a summary of health history data.

Biographic data

Begin obtaining the patient’s health history by reviewing personal information. This data section identifies the patient and provides important demographic information, such as the patient’s address, telephone number, age, sex, birth date, Social Security number, place of birth, race, nationality, marital status, occupation, education, religion, cultural background, and emergency contact person.

Health and illness patterns

This information includes the patient’s chief complaint; current, past, and family health history; status of physiologic systems; and developmental considerations.

Mind his P’s and Q’s

Determine why the patient is seeking health care by asking, “What brings you here today?’’ If the patient has specific symptoms, record that information in the patient’s own words. Ask the patient with a specific symptom or health concern to describe the problem in detail, including the suspected cause. To ensure that you don’t omit pertinent data, use the PQRST mnemonic device, which provides a systematic approach to obtaining information. (See PQRST: What’s the story?.)

For a patient who seeks a health maintenance assessment, health counseling, or health education, expect to take few notes.

Think back

Next, record childhood and other illnesses, injuries, previous hospitalizations, surgical procedures, immunizations, allergies, and medications taken regularly.

Tell me about your mother

Information about the patient’s relatives can also unmask potential health problems. Some diseases, such as cardiovascular disease, alcoholism, depression, and cancer, may be genetically linked. Others, such as hemophilia, cystic fibrosis, sickle cell anemia, and Tay-Sachs disease, are genetically transmitted.

Genogram and grampa, too

Determine the general health status of the patient’s immediate family members, including maternal and paternal grandparents, parents, siblings, aunts, uncles, and children. If any are deceased, record the year and cause of death. Use a genogram to organize family history data.

PQRST: What’s the story?

Nursing process

 

Information about the patient’s past and current physiologic status (also called review of systems) is another health history component. Starting from the head and systematically proceeding to the toes, ask the patient about any past or present symptoms of disease in each body system. A careful assessment helps identify potential or undetected physiologic disorders.

Health promotion and protection patterns

What a patient does or doesn’t do to stay healthy is affected by such factors as health beliefs, personal habits, sleep and waking patterns, exercise and activity, recreation, nutrition, stress and coping, socioeconomic status, environmental health patterns, and occupational health patterns. To help assess health promotion and protection patterns, ask the patient to describe a typical day and inquire about
which behaviors the patient believes are healthful.

Role and relationship patterns

A patient’s role and relationship patterns reflect his psychosocial (psychological, emotional, social, spiritual, and sexual) health. To assess role and relationship patterns, investigate the patient’s self-concept, cultural influences, religious influences, family role and relationship patterns, sexuality and reproductive patterns, social support patterns, and other psychosocial considerations. Each of these patterns can influence the patient’s health.

Summary of health history data

Conclude the health history by summarizing all findings. For the well patient, list the patient’s health promotion strengths and resources along with defined health education needs. If the interview points out a significant health problem, tell the patient what it is and begin to address the problem. This may involve referral to a doctor or other practitioner, education, or plans for further investigation.

Physical assessment

Perform hand hygiene in front of the patient before beginning the physical assessment. Use drapes so only the area being examined is exposed. Develop a pattern for your assessments, starting with the same body system and proceeding in the same sequence. Organize your steps to minimize the number of times the patient needs to change position. By using a systematic approach, you’ll be less likely to forget an area.

Count ’em — four

No matter where you start your physical assessment, you’ll use four techniques:

  1. inspection
  2. palpation
  3. percussion
  4. auscultation

Use these techniques in sequence except when you perform an abdominal assessment. Because palpation and percussion can alter bowel sounds, the sequence for assessing the abdomen is inspection, auscultation, percussion, and palpation. Let’s look at each step in the sequence.

Inspection

Inspect the patient using vision, smell, and hearing to observe normal conditions and deviations. Performed correctly, inspection can reveal more than other techniques.

Inspection begins when you first meet the patient and continues throughout the health history and physical examination. As you assess each body system, observe for color, size, location, movement, texture, symmetry, odor, and sounds.

Palpation

Palpation requires you to touch the patient with different parts of your hands, using varying degrees of pressure. To do this, you need short fingernails and warm hands. Always palpate tender areas last. Tell your patient the purpose of your touch and what you’re feeling with your hands.

Palpate to evaluate

As you palpate each body system, evaluate the following features:

  • texture — rough or smooth?
  • temperature — warm, hot, or cold?
  • moisture — dry, wet, or moist?
  • motion — still or vibrating?
  • consistency of structures — solid or fluid-filled?

Percussion

Percussion involves tapping your fingers or hands quickly and sharply against parts of the patient’s body, usually the chest or abdomen. The technique helps you locate organ borders, identify organ shape and position, and determine if an organ is solid or filled with fluid or gas. (See Percussion types.)

Do you hear what I hear?

Percussion requires a skilled touch and an ear trained to detect slight variations in sound. Organs and tissues, depending on their density, produce sounds of varying loudness, pitch, and duration. For instance, air-filled cavities, such as the lungs, produce markedly different sounds than do the liver and other dense tissues. (See Sounds and their sources.)

As you percuss, move gradually from areas of resonance to those of dullness and then compare sounds. Also, compare sounds on one side of the body with those on the other side.

Percussion types

Nursing process

 

Auscultation

Auscultation, usually the last assessment step, involves listening for various breath, heart, and bowel sounds with a stethoscope. To prevent the spread of infection among patients, clean the heads and end pieces of the stethoscope with alcohol or a disinfectant after every use.

Diagnostic test findings

Diagnostic test findings complete the objective database. Together with the nursing history and physical examination, they form a significant profile of the patient’s condition.

Sounds and their sources

Nursing process

 

Analyzing the data

The final aspect of assessment involves analyzing the data you’ve compiled. In your analysis, include the following steps:

  • Group significant data into logical clusters. You’ll base your nursing diagnosis not on a single sign or symptom but on a cluster of assessment findings. By analyzing the clustered data and identifying patterns of illness-related behavior, you can begin to perceive the patient’s problem or risk of developing other problems.
  • Identify data gaps. Signs, symptoms, and isolated incidents that don’t fit into consistent patterns can provide the missing facts you need to determine the overall pattern of your patient’s problem.
  • Identify conflicting or inconsistent data. Clarify information that conflicts with other assessment findings, and determine what’s causing the inconsistency. For example, a patient with diabetes who says that she complies with her prescribed diet and insulin administration schedule, but whose serum glucose is greatly elevated, may need to have her treatment regimen reviewed or revised.
  • Determine the patient’s perception of normal health. A patient may find it harder to comply with the treatment regimen when his idea of “normal” doesn’t agree with yours.
  • Determine how the patient handles his health problem. For instance, is the patient coping with his health problem successfully, or does he need help? Does he deny that he has a problem, or does he admit it but lack solutions to the problem?
  • Form an opinion about the patient’s health status. Base your opinion on actual, potential, or possible concerns reflected by the patient’s responses to his condition and use this to formulate your nursing diagnosis.

Nursing process: Nursing diagnosis

Focus Topic: Nursing process

In 1990, NANDA International (NANDA-I) defined the nursing diagnosis as “a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Nursing diagnoses provide the basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable.”

Identify, diagnose, and validate

In forming a nursing diagnosis, you’ll identify the patient’s problem, write a diagnostic statement, and validate the diagnosis. You’ll establish several nursing diagnoses for each patient. Arrange the diagnoses according to priority so that you address the patient’s most crucial problems first.

Identifying the problem

The first step in developing a nursing diagnosis is to identify the problem. To do this, you must assess the patient and obtain clinical information. Then organize the data obtained during the assessment and determine how the patient’s basic needs can be met. The problem identified can be either actual or potential. The diagnosis must be one that can be resolved by a nurse working within her scope of practice.

Writing the diagnostic statement

The diagnostic statement consists of a nursing diagnosis and the etiology (cause) related to it. For example, a diagnostic statement for a patient who’s too weak to bathe himself properly might be Bathing or hygiene self-care deficit related to weakness. A diagnostic statement related to an actual problem might be Impaired gas exchange related to pulmonary edema. A statement related to a potential problem might be Risk for injury related to unsteady gait.

Stress present, balance absent

The etiology is a stressor or something that brings about a response, effect, or change. A stressor results from the presence of a stress agent or the absence of an equilibrium factor. Causative agents may include birth defects, inherited factors, diseases, injuries, signs or symptoms, psychosocial factors, iatrogenic factors, developmental phases, lifestyle, or situational or environmental factors.

Validating each diagnosis

Next, validate the diagnosis. Review clustered data. Are they consistent? Does the patient verify the diagnosis? If not, you may need to relook at the data and modify the diagnosis.

Prioritizing the diagnoses

After you’ve established several nursing diagnoses, categorize them in order of priority. Obviously, life-threatening problems must be addressed first, followed by health-threatening concerns. Also, consider how the patient perceives his health problem; his priority problem may differ from yours.

Maslow’s hierarchy

One system of categorizing diagnoses uses Maslow’s hierarchy of needs, which classifies human needs based on the idea that lower-level, physiologic needs must be met before higher-level, abstract needs. For example, if a patient has shortness of breath, he probably isn’t interested in discussing his relationships. (See Maslow’s hierarchy of needs.)

Nursing process: Planning

Focus Topic: Nursing process

After you establish the nursing diagnoses, you’ll develop a written care plan. A written care plan serves as a communication tool among health care team members that helps ensure continuity of care. The plan consists of two parts: patient outcomes, or expected outcomes, which describe behaviors or results to be achieved within a specified time; and the nursing interventions needed to achieve those outcomes.

Maslow’s hierarchy of needs

Nursing process

 

Measure and observe

Be sure to state both parts of the care plan in measurable, observable terms and dates. The statement, “The patient will perceive himself with greater self-worth,’’ is too vague, lacks a time frame, and offers no means to observe the patient’s self-perception. A patient outcome such as, “The patient will describe himself in a positive way within 1 week,” provides an observable means to evaluate the patient’s behavior and a time frame for the behavioral change. (See Ensuring a successful care plan.)

Intervention options

Before you implement a care plan, review your intervention options and then weigh their potential to succeed. Determine if you can obtain the necessary equipment and resources. If not, take steps to get what you need or change the intervention accordingly. Observe the patient’s willingness to participate in the various interventions and be prepared to postpone or modify interventions if necessary.

Ensuring a successful care plan

Nursing process

 

Nursing process: Implementation

Focus Topic: Nursing process

The implementation phase is when you put your care plan into action. Implementation encompasses all nursing interventions directed at solving the patient’s problems and meeting health care needs. While you coordinate implementation, you also seek help from the patient, the patient’s family, and other caregivers.

Monitor and gauge

After implementing the care plan, continue to monitor the patient to gauge the effectiveness of interventions and adjust them as the patient’s condition changes. Documentation of outcomes achieved should be reflected in the care plan. Expect to review, revise, and update the entire care plan regularly, according to facility policy. Keep in mind that the care plan is usually a permanent part of the patient’s medical record.

Nursing process: Evaluation

Focus Topic: Nursing process

After enough time has elapsed for the care plan to effect desired changes, you’re ready for evaluation, the final step in the nursing process. During evaluation, you must decide if the interventions carried out have enabled the patient to achieve the desired outcomes.

Start with the finish

Begin by reviewing the patient outcomes stated for each nursing diagnosis. Then observe your patient’s behavioral changes and judge how well they meet the outcomes related to them. Does the patient’s behavior match the outcome or fall short of it? Consider the evaluation to be positive if the patient’s behavior has changed as expected, if the outcomes have been accomplished, or if progress has occurred. Failure to meet these criteria constitutes a negative evaluation and requires new interventions.

Process success

The evaluation phase also allows you to judge the effectiveness of the nursing process as a whole. If the process has been applied successfully, the patient’s health status will improve. Either his health problems will have been solved or progress will have been made toward achieving their resolution. He’ll also be able to perform self-care measures with a sense of independence and confidence, and you’ll feel assured that you’ve fulfilled your professional responsibility.

[/sociallocker]

 

FURTHER READING/STUDY:

Resources: