The Nursing Process (page 2)
Regardless of practice area or specialty, nurses use the same framework of nursing care, called the nursing process. The American Nurses Association describes the nursing process as the crucial core of practice delivering holistic, client-focused nursing care. Originally a five-phase process, the nursing process today consists of six phases: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.
Assessment: Assessment is the systematic collection of subjective (what the client says) and objective (what the nurse sees, hears, smells, and feels) information from the client. During this phase, nurses consider the physical, psychological, sociocultural, and spiritual factors that may affect the client's health situation. Nurses perform initial, comprehensive assessments when they first admit a client to a hospital setting, when they accept a new client into a physician's office or clinic, and when they first visit a home healthcare client. These assessments are quite detailed and require significant time to perform because of the amount of data needed when clients have problems that have yet to be identified. Nurses complete focused assessments on clients whose problem has been identified to note whether that problem has worsened, improved, or resolved. These assessments are shorter in duration and more concise, and they are typically performed on a regular basis. For example, a nurse working in an intensive care unit may assess a client's blood pressure every few minutes. Time-elapsed visits also require nursing assessment. These vary in duration and frequency, depending on the client's health issues. Examples include annual health visits for children or interval assessments for weight reduction. The last but crucial type is emergency assessment for life-threatening situations when nurses must remember their ABCs—airway, breathing, and circulation, especially for clients with heart or lung problems. Nurses must also have emergency psychological skills in order to assess clients who may want to kill themselves or harm others.
Diagnosis: While APNs can make medical diagnoses, most nurses cannot. Nurses diagnose human responses to actual or potential health problems after analyzing and interpreting the data they collect from their assessment. The North American Nursing Diagnosis Association (NANDA) defines nursing diagnosis as "a clinical judgment about individual, family or community responses to actual or potential health problems or life processes, which provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable." Nursing diagnoses guide the selection of interventions that are likely to produce the desired treatment effects and determine nurse-sensitive outcomes. They also provide a means of communicating client care requirements to other nurses.
Outcomes identification: Nurses use assessments and diagnoses to create measurable and achievable short- and long-term goals. The newest addition to the nursing process, outcome identification, provides individualized care, promotes client participation, plans care that is realistic and measurable, and allows for the involvement of support personnel. Nurses use their knowledge and skills to prioritize client outcomes. High priorities include lifethreatening situations like hemorrhaging, events that require immediate attention such as discharge planning, and issues that are extremely important to the client such as pain. Low priorities involve problems that usually resolve with little attention, such as discomfort from minor surgery.
Planning: Planning refers to the development of nursing strategies that can alleviate the client's problems. To meet the standards of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), the plan must be developed by an RN, documented in the client's healthcare record, and reflect the standards of care established by the institution and the profession. Medicare and Medicaid, and some third-party reimbursement plans (e.g., health insurance) require care plans for each client.
Implementation: Nurses implement client care according to the care plan to assure the continuity of care during hospitalization, discharge, and home care. The purpose of this action phase of the nursing process is to provide individualized therapeutic and technical care to help the client achieve an optimal level of health. Nurses may delegate some interventions to other members of the healthcare team; however, RNs maintain the responsibility and accountability for the supervision and evaluation of these personnel.
Evaluation: RNs continuously evaluate both the client's status and the effectiveness of the client's care. They then modify the care plan as needed. During this phase, nurses conduct a thorough, systematic review of the effectiveness of their nursing interventions and a determination of client goal achievement. The nurse appraises goal attainment jointly with the client. While evaluation is a distinct phase, it occurs throughout the nursing process to assure prompt reassessment, rediagnosing, and replanning when needed.
Making a Difference, One Patient at a Time, by Jolynn Sannicandro
My preceptor and I stood outside a room as she gave me the report on a patient who was admitted that morning. She explained to me that the patient was fresh out of surgery for a total laryngectomy and that the patient's voice box had been completely removed due to laryngeal cancer. My preceptor further identified my objectives for the morning, which included assessing the patient from head to toe, obtaining vital signs every four hours, monitoring output, suctioning the patient, changing the patient's feeding tubes, and providing wound care.
As my preceptor left to tend to another patient, I took a deep breath and walked into the patient's room. She was sitting in a chair with her feet elevated on a stool and a trachea collar attached to oxygen and humidified air. There were two drains located below the right and left clavicles, which appeared to be patent based on the accumulation of fluid. I grasped the stethoscope around my neck and proceeded to introduce myself. As I began my full body assessment, I observed other devices attached to the patient that I had learned about in lecture and seen in clinical practice, such as a catheter and a nasogastric tube. The catheter was properly placed by the nurse. It was taut against her thigh and below the bladder. The nasogastric tube was connected to a pump and there was formula flowing from the feeding bag through the tube and into the patient. The woman had a nervous but kind smile and warm eyes behind thick round glasses. The patient's fear for her own well-being was compounded by her awareness of my own self-doubt. This being only my second day at this hospital, I was still experiencing the butterflies that come with every unfamiliar and challenging experience. However, I placed my own apprehension aside and thought back to the nursing classes that had more than adequately prepared me for the current situation I was in, dealing with a patient who was scared and needed a medical professional who she could trust. I had no idea that this initial placing of trust would be the beginning of the kind of relationship that is at the heart of the nursing profession.
The patient remained under the hospital's care for several weeks. I was assigned this same patient every clinical rotation and began to grow closer to her. Although communicating was difficult because everything she wanted to say to me had to be written on a notepad, I was still able to read her emotionally by looking for nonverbal cues. As a nursing student I had been trained to become more aware of a patient's emotional state by observing for something as subtle as a slight change in a patient's facial expression.
I was also able to glimpse the life of the patient through her large, close-knit family, who visited her daily. I came to know the patient's family when they would visit her to play board games, watch her favorite soap opera, or share stories about their day. Throughout these visits I saw the interactions the family members had with the patient and quickly realized how important her family was to her.
One day after a visit by the family members I was checking the patient's vital signs; she tapped me on the shoulder to show me a note she had just written on her pad that said, "Do you think I will be out of here in a month to see my niece get married?" Taking her hand in mine I told her that I could not promise her when she would be discharged from the hospital, because I did not want to instill in her a false sense of hope. However, I assured her that the healthcare professionals and I would be there with her every step of the way on her journey toward recovery. With that, the patient gave me a smile and squeezed my hand.
After I assured the patient that I would be there for her, I made sure she continued to build her strength by walking around the floor with her, washing her hair, or just simply spending time with her when her family was not there. As I did these things, I could see before my own eyes that her health and morale were slowly improving. This pattern continued for several weeks before she was finally discharged from the hospital. On her last day, the day before her niece's wedding, she wrote me one last note that said, " I couldn't have done this without you; I love you." After giving her a hug and a kiss, I realized that moments like this are why I wake up early for clinical and spend long hours in the library. I truly felt, and her note confirmed, that I was an integral part of this woman's recovery. The experience I encountered with this patient showed me that this career allows me to touch the lives of people in ways that people in other fields will never get to experience.