CHAPTER 4: The Nursing Process Show Chapter 4 The Nursing Process The problem solving model for nursing is called the nursing process. The nursing process consists of the assessment, nursing diagnosis, planning, intervention, and evaluation. In the assessment process, you look at the patient from head to toe, and also family, and community support. Next, you formulate the nursing diagnosis, which is the problem. Then, you plan on the things you should do to resolve the nursing diagnosis. Afterwards, you implement the interventions to the patient. Finally, you evaluate whether what you implemented improved the client�s or patient�s condition or not. The nursing process is a thoughtful, deliberate use of a problem-solving approach to nursing. This process will form the structure by which you function. You will need to consult a text on nursing theory for a complete understanding of the nursing process. Assessment Assessment is the process of gathering information, analyzing information, and identifying problems. The basic purpose of some skills is to gather information. For every skill that you utilize, however, you must collect appropriate information to implement the skill correctly and safely. In addition to carrying out the specific assessment listed, you should always be observant while performing the procedure. It is an excellent time to gain further information about the patient. You may extend your knowledge of existing problems or gain insight that will lead you to identify new ones (Ellis, Nowlis, Bentz, 1992). Nursing assessments do not focus upon disease, as do medical assessments. Nursing assessments focus upon a client�s response to a health problem. Nursing assessment should include the clients� perceived needs, health problems, related experience, health practices, values, and lifestyles. The assessment process involves four closely related activities: collecting data, organizing data, validating data, and documenting data Collecting Data Data collection is the process of gathering information about a client�s health status. It must be both systematic and continuous to prevent the omission of significant data and reflect a client�s changing health status. A baseline data is all the information about a client; it includes the nursing health history, physical assessment, the physician�s history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. Client data should include past history as well as current problems Types of Data Data can be subjective or objective. Subjective data, also referred to as symptoms are apparent only to the person affected and can be described or verified only by that person. Subjective data include the client�s sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation. Objective data, also referred to as signs are detectable by an observer or can be tested against an accepted standard. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination. For example, subjective data is when a patient states �I am hurting.� Objective data is when the nurse observes that the patient is grimacing and holding on to his stomach. Sources of Data Sources of data can be primary or secondary. The client is the primary source of data. Family members or other support persons, other health professionals, records and reports, laboratory and diagnostic analyses, and relevant literature are called secondary sources. Data Collection Methods The primary methods used to collect data are observing, interviewing, and examining. Observation occurs whenever the nurse is in contact with the client or support persons. Interviewing is used mainly while taking the nursing health history. Examining is the major method used in the physical health assessments. This will be discussed in detail in Chapter 8. There are four kinds of interview questions, namely, closed or open-ended questions, and neutral or leading. Closed questions used in the directive interview, are restrictive and generally require only �yes� or �no� or short factual answers giving specific information. Examples of closed questions are �What medication did you take?� �Are you having pain now?� �When did you fall?� The stressed person and the person who has difficulty communicating will find closed questions easier to answer. However, if you need more information, open-ended questions are more appropriate. They allow clients the freedom to talk about what they wish. Examples are �Tell me about the medication you are taking.� �Tell me about your pain you are having.� �Tell me about the fall.� A neutral question is a question the client can answer without direction or pressure from the nurse. Examples are �How do you feel about that?� �Why do you think you had the operation?� These type of questions allow the patient to think for themselves. A leading question directs the client�s answer. The phrasing of the question suggests what answer is expected. Examples are �You�re stressed about surgery tomorrow, aren�t you?� �You don�t like the medicine, do you?� These type of questions can create problems if the client, in an effort to please the nurse, gives inaccurate responses. This can result in inaccurate data. When interviewing, the nurse must schedule the best time and well-lighted, well-ventilated, free of noise environment. A seating arrangement with the nurse behind a desk and the client seated across creates a formal setting. In contrast, a seating arrangement in which the parties sit on two chairs placed at right angles to a desk or table or a few feet apart, with no table between, creates a less formal atmosphere. The distance between the interviewer and interviewee should be neither too small nor too great, because people feel uncomfortable when talking to someone who is too close or too far away. Most people feel comfortable maintaining a distance of 3 to 4 feet during an interview. Stages of Interview An interview has three major stages, the opening or introduction, the body or development, and the closing. The opening can be the most important part of the interview because what is said and done at that time sets the tone for the remainder of the interview. Its purpose is to establish rapport and trust. Example of an opening is �Good morning Mr. Jones, I am Judy Oliver, a nursing student,� accompanied by nonverbal gestures, such as a smile, a handshake, and a friendly manner. The body of an interview is the part in which the client communicates what he or she think, feels, know, and perceives in response to questions from the nurse. An example of this interview part is �What brought you to the hospital today?� The closing is the part when the nurse had gathered all the information she requires for the objective part of assessment. The closing is important in maintaining the rapport and trust and in facilitating future interactions. Signal that interview is coming to an end by offering to answer questions: �Do you have any questions?� Declare completion of task. State appreciation or satisfaction what was accomplished in the interview. Express concern for the person�s welfare and future. Plan for the next meeting, if there is to be one. Reveal what will happen next. Signal that time is up if a time limit was agreed in the beginning. Finally, provide summary to verify accuracy and agreement. Objective Part of Data Collection The physical examination or physical assessment is a systematic data-collection method that uses observational skills, such as the senses of sight, hearing, smell, and touch, to detect health problems. To conduct the examination the nurse uses techniques of inspection, auscultation, palpation, and percussion. This will be discussed in Chapter 8. Organizing Data The nurse uses a framework to organize the data collected. Most schools of nursing and health care providers have developed their own structured assessment tools which can be based on nursing theories. Example of these nursing models are the Roy Adaptation Model and Orem�s Self-Care Model. Example of nonnursing model is Maslow�s Hierarchy of Needs. Nursing Models Roy�s Adaptation Model 1. Physiologic needs Activity and rest NutritionElimination Fluid and electrolytes Oxygenation Protection Regulation: temperature Regulation: the senses Regulation: endocrine system 2. Self-concept Physical self Personal self3. Role function 4. Interdependence Orem�s Self-Care Model Universal Self-Care Requisites 1. The maintenance of a sufficient intake of air. 2. The maintenance of a sufficient intake of water. 3. The maintenance of a sufficient intake of food. 4. The provision of care associated with elimination processes and excrement. 5. The maintenance of a balance between activity and rest. 6. The maintenance of a balance between solitude and social interaction. 7. The prevention of hazards to human life, human functioning, and human well- being. 8. The promotion of human functioning and development within social groups in accord with human potential, known human limitations, and human desire to be normal. Nonnursing Models Maslow�s Hierarchy of Needs These human needs must be met by the client in order of priority. First need: Physiologic needs Second need: Safety and security needs Third need: Love and belonging needs Fourth need: Self-esteem needs Last need: Self-actualization needs (Kozier, Erb, Berman, and Burke, 2000).
Validating Data Validation is the act of double checking or verifying data to confirm that they are accurate and factual. Validating data ensures that assessment information is complete. The objective and subjective data agree. You may also obtain additional information that may have been overlooked. Validating data is done by comparing subjective and objective data, clarifying ambiguous statements, making sure that the data consist of what the clients says, and by using references, such as textbooks, journals, and research reports. Documenting Data Accurate documentation is essential and should include all data collected about the client�s health status. Data are recorded in a factual manner and not interpreted by the nurse. The next step of the nursing process after assessment is the nursing diagnosis (Kozier, Erb, Berman, and Burke, 2000). Nursing Diagnosis Nursing Diagnosis is the process in which you classify the problem in the assessment phase into an approved classification process called NANDA which stands for North American Nursing Diagnosis Association. A nursing diagnosis is a clinical diagnosis made by a registered nurse which, unlike physician's diagnosis, does not cover the patient's medical condition, but the patient's response to the medical condition. Patients generally have multiple nursing diagnoses covering everything from their physical well-being through their psychosocial well-being to the well-being of their family and caregivers. These diagnoses must cover problems that the nurse can treat independently of the MD. A complete nursing diagnosis is written in the format problem related to cause of problem as evidenced by symptoms of problem ( www.everything2..com retrieved on 07/02/2008). An example of such a nursing diagnosis based on the nursing assessment above would be Impaired gas exchange related to productive cough as evidenced by shallow respiration of 32, oxygen saturation of 89 %, inspiratory crackles auscultated throughout right upper and lower chest, diminished breath sounds on right side and complaint of �can�t breathe lying down� and short of breath of exertion. You can formulate nursing diagnosis by looking up the NANDA list of nursing diagnosis while basing it on the assessment data acquired.NANDA, the North American Nursing Diagnosis Association, has an approved list of nursing diagnoses which may be used in North America. There is also an international association attempting to create a list of nursing diagnoses which will hopefully become universal at some point in the future.
What are possible sources of information to use in the assessment step of the nursing process quizlet?Identify four sources of assessment data. The primary source of information is the client (physical assessment and interview). Secondary sources include the client's family, reports, test results, information in current and past medical records, and discussions with other health care providers.
What are the sources of information in nursing?Most information sources in the nursing literature are medical journal articles followed by articles from nursing and other journals. This is particularly true among articles in clinical specialty journals.
What sources can you use to gather information about your patient?Depending on the measure, data can be collected from different sources, including medical records, patient surveys, and administrative databases used to pay bills or to manage care.
Which task is included in the assessment step of the nursing process?Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
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