Chapter 7 ATI: The nursing process (Everything, easy to understand)

Assessment/Data Collection

The first step of the nursing process. It involves systematically collecting information about the client’s health status to identify their needs and determine what additional data should be collected.

Types of assessment

Nurses can collect data during an initial assessment (baseline data), focused assessment, and ongoing assessments.

Methods of data collection

Observation, interviews with clients and families, medical history, comprehensive or focused physical examination, diagnostic and laboratory reports, and collaboration with other members of the health care team.

To collect data effectively

Nurses must ask appropriate questions, listen carefully to responses, and have excellent head-to-toe physical assessment skills.

Clinical judgment and critical thinking during assessment

Nurses must recognize when assessment data needs to be collected and recognize the need to collect assessment data prior to interventions.

Subjective data

Information about the client’s feelings, perceptions, and descriptions of their health status.

Subjective data — who can verify it?

Clients are the only ones who can describe and verify their own manifestations.

Subjective data — when is it collected?

Nurses collect subjective data (manifestations) during a nursing history.

Examples of subjective data

A client’s pain rating and a client’s description of their pain.

Objective data

Information the nurse can feel, see, hear, or smell through observation or physical assessment of the client.

Objective data — when is it collected?

Nurses observe and measure objective data (findings) during a physical examination.

Examples of objective data

Respiratory rate, skin color, temperature, characteristics, and observing that the client is walking with a limp.

During assessment/data collection

The nurse validates, interprets, and clusters data.

Documentation of assessment data

Must be thorough, concise, and accurate.

Objective Data

An assistive personnel reports that the client walks with a limp.

Objective Data

The client’s skin is consistent with genetic background, warm, and dry.

Objective Data

Respiratory rate is even and unlabored at 22/min.

Subjective Data

The client’s pain rating is 3 on a scale of 0 to 10.

Subjective Data

The client’s partner states, “They had burning leg pain after walking 10 minutes.”

Well done! Objective and subjective data

The nurse should analyze cues to identify objective and subjective data.

Objective data

Includes information the nurse can feel, see, hear, or smell, through observation or physical measurement, such as respiratory rate, skin color, temperature, and characteristics, and observation that the client is walking with a limp.

Subjective data

Includes a client’s feelings, perceptions, and descriptions of health status, such as pain level, description of pain, and contributing factors to pain.

Assessment/Data collection

“I will review the past medical history in the client’s medical record to obtain more information about the client.”

Assessment/data collection step

Reviewing the past medical history in the client’s medical record provides more information about the client.

Assessment/Data collection

The newly licensed nurse asks the client to rate the severity of the pain on a scale of 0 to 10.

Assessment/data collection step

Asking the client to rate the severity of pain on a scale of 0 to 10 is part of assessment/data collection.

Analysis/Diagnosis/Data Collection

Nurses use critical thinking and diagnostic reasoning to determine the client’s health status or issues.

During analysis/diagnosis/data collection

Nurses analyze and monitor collected data, make nursing judgments about health status or coping mechanisms, and use critical thinking to guide nursing care.

Analysis/diagnosis/data collection requires nurses to look at the data and

Identify patterns or trends.

Analysis/diagnosis/data collection requires nurses to look at the data and

Compare the data with expected standards or reference ranges.

Analysis/diagnosis/data collection requires nurses to look at the data and

Arrive at conclusions to guide nursing care.

RNs make multiple analyses

RNs interpret collected data and use reasoning and judgment to determine which data account for the client’s health status or problems.

Further data collection and analysis

Sometimes nurses need to collect additional data and perform additional analysis.

Clustering collected data

A specific finding might serve as an alert to a specific problem that requires planning and intervention.

Documentation during analysis/diagnosis/data collection

Complete and accurate documentation is essential. Documentation should focus on facts and should be highly descriptive.

Analysis/ Diagnosis/Data Collection

The newly licensed nurse documents that the client’s pain is causing the client to take shallow breaths and could lead to complications such as atelectasis.

Analysis/ diagnosis/data collection step

Documenting that the client’s pain is causing the client to take shallow breaths and could lead to complications such as atelectasis is part of analysis/diagnosis/data collection. The nurse clusters and interprets data to determine a conclusion.

Analysis/ Diagnosis/Data Collection

“I will review objective and subjective client data to identify a potential client problem.”

Analysis/ diagnosis/data collection step

Reviewing objective and subjective client data to identify a potential client problem is part of analysis/diagnosis/data collection. The nurse clusters and interprets data to determine a conclusion.

Planning

When planning client care (RN) or contributing to a client’s plan of care (PN), nurses establish priorities and optimal outcomes that can be measured and evaluated.

Purpose of established priorities and outcomes

They direct nurses in selecting interventions to include in a plan of care to promote, maintain, or restore health of clients.

Three types of planning

Comprehensive planning, ongoing planning, and discharge planning.

Comprehensive plan of care

Nurses initially develop a comprehensive plan of care based on comprehensive assessments they complete, such as on admission to a health care facility or to a home health organization.

Ongoing planning

Nurses perform ongoing planning throughout the provision of care. While obtaining new information and evaluating responses to care, they modify and individualize the initial plan of care.

Discharge planning

A process of anticipating and planning for clients’ needs after discharge.

When should discharge planning begin?

Discharge planning must begin during admission to be effective.

Throughout the planning process

Nurses set priorities, determine expected client outcomes, and select specific nursing interventions.

Priority setting

Nurses identify a preferential order of client problems. This guides the delivery of nursing care.

Guidelines for setting priorities

Nurses can use guidelines to set priorities, such as Maslow’s hierarchy of basic needs.

Maslow’s hierarchy of basic needs

A pyramid with five labeled levels arranged from bottom to top as physiological, safety and security, love and belonging, self-esteem, and self-actualization.

Maslow’s hierarchy — bottom to top

Physiological → safety and security → love and belonging → self-esteem → self-actualization.

Goals and outcomes

Nurses work with clients to identify goals and outcomes.

Goals

Identify optimal status.

Outcomes

Identify the observable criterion that will determine success or failure of the goal.

Goals and outcomes — relationship

These terms are often interchangeable.

Goal/outcome requirements

The goal/outcome must be client-centered, singular, observable, measurable, time-limited, mutually agreeable, and reasonable.

SMART acronym

Specific, Measurable, Attainable, Realistic, and Timely.

Concise, measurable goals

Help nurses and clients evaluate progress.

Short- and long-term goals

Guide the client toward the planned outcome and help determine the effectiveness of nursing care.

Nursing interventions

Actions nurses identify to achieve optimal outcomes. Scientific principles provide the rationale for nursing interventions.

Nurse-initiated/independent interventions

Nurses use evidence and scientific rationale to take autonomous actions to benefit clients.

Nurse-initiated/independent interventions — basis

Nurses base these actions on identified problems and health care needs and make sure they are within their scope of practice.

Nurse-initiated/independent interventions — accountability

Nurses perform or delegate the interventions and are accountable for them.

Nurse-initiated/independent interventions — example

Repositioning a client at least every 2 hr to prevent skin breakdown.

Provider-initiated/dependent interventions

Interventions nurses initiate as a result of a provider’s prescription (written, standing, or verbal) or the facility’s protocol.

Provider-initiated/dependent interventions — example

Blood administration procedures.

Collaborative interventions

Interventions nurses carry out in collaboration with other health care team professionals.

Collaborative interventions — example

Ensuring that a client receives and eats their evening snack.

Nursing care plan (NCP)

The end product of the planning step.

Purpose of the nursing care plan (NCP)

Nurses organize the NCP for quick identification of problems, outcomes, and interventions to implement.

Provider-initiated

Writing a prescription for morphine as needed for pain.

Provider-initiated

Inserting a nasogastric tube to relieve gastric distention.

Nurse-initiated

Repositioning a client every 2 hr to reduce pressure injury risk.

Nurse-initiated

Performing a daily bath after the evening meal.

Nurse-initiated

Showing a client how to use progressive muscle relaxation.

Well done! Nursing interventions

Nursing interventions that require a provider’s prescription include prescription for medications and insertion of a nasogastric tube. Nurse-initiated interventions include showing a client how to use progressive muscle relaxation, performing an evening bed bath, and repositioning a client to reduce pressure injury risk.

Planning

The newly licensed determines the client is due to receive the pain medication and prepares to administer a dose to the client.

Planning step

Determining that the client is due to receive pain medication and preparing to administer a dose is part of planning.

Planning

“I will determine the most important client problems that we should address.”

Planning step

Prioritizing client problems is part of the planning step.

Implementation

Nurses base the care they provide on assessment data, analyses/diagnosis/data collection, and the plan of care developed in the previous steps.

Purpose of implementation

Nurses use problem-solving, clinical judgment, and critical thinking to select and implement appropriate therapeutic interventions.

Implementation — what guides care?

Nursing knowledge, priorities of care, and planned goals or outcomes guide care.

Goal of implementation

Promote, maintain, or restore health.

Interpersonal skills during implementation

Therapeutic communication.

Technical skills during implementation

Psychomotor performance.

Therapeutic interventions

Include measures nurses take to minimize risk, such as wearing personal protective equipment.

Unplanned events

Nurses intervene in response to an observation of unsafe practice, a change in status, or the emergence of a life-threatening situation.

Evidence-based rationale

Nurses use evidence-based rationale for the selection and implementation of all therapeutic interventions.

Caring and professional behavior

Should be at the center of all therapeutic nursing interventions.

During implementation

Nurses perform nursing actions, delegate tasks, supervise other health care staff, and document delivery of care and clients’ responses.

Implementation

The newly licensed nurse administered the pain medication to the client.

Implementation step

Administering the pain medication to the client is part of the implementation step of the nursing process.

Implementation

“I will administer prescriptions from the provider.”

Implementation step

Administering prescribed medications to the client is part of the implementation step.

Evaluation

Nurses evaluate clients’ responses to nursing interventions and form a clinical judgment about the extent to which clients have met the goals and outcomes.

Continuous evaluation

Nurses continuously evaluate clients’ progress toward outcomes.

Using client data during evaluation

Nurses use clients’ data to determine whether to modify the plan of care.

Effectiveness of the nursing care plan

Nurses compare client data to the planned outcome criteria to determine what further actions to take.

Clients’ outcomes in specific, measurable terms

Are easier to evaluate.