chapter 3 fundamentals

five steps of the nursing process

• • Assessment → Diagnosis → Planning → Implementation → Evaluation (ADPIE)

nursing process=Assessment

• Gathering data about the patient and the patient’s health status

• • Assessment provides the foundation for the nursing process

nursing process=Diagnosis

• Nurse uses critical-thinking skills

• Analyzes assessment data

• Identifies patterns

• Determines strengths, problems, and factors contributing to problems

nursing process=Planning

• Identifying goals and outcomes

• Choosing interventions

• • Creating the nursing care plan

nursing process=implementation

• Identifying goals and outcomes

• Choosing interventions

• Creating the nursing care plan

nursing process= Performing or delegating planned interventions

• • This is when the nurse carries out the care plan

nursing process=

Evaluation

Last step of the nursing process

• Determines the patient’s progress toward desired outcomes

• • Evaluates the effectiveness of the nursing care plan

THE FIRST STEP OF THE NURSING PROCESS

• Assessment = systematic gathering of information

• Includes the patient’s:

  • Physiological

  • Psychological

  • Social

  • Individual

  • Developmental

  • Spiritual

• • Cultural status

the foundation of the entire nursing process.

Purpose of assessment

• Provides contextual information for the patient’s database

• Supplies data needed for nursing diagnosis

• Identifies motivation and resources

• Helps guide effective interventions

• • Provides a guide for reassessment during evaluation

 TYPES AND SOURCES OF DATA

Subjective Data

• Also called covert data

• What the patient reports or tells you

• Cannot be directly observed or measured by the nurse

• Based on the patient’s feelings, perceptions, thoughts, and experiences

• Examples:

  • Pain

  • Nausea

  • Dizziness

  • Fatigue

  • Feeling anxious

  • Patient’s description of symptoms

= what the PATIENT SAYS or FEELS

⭐ Easy way to remember:

Says → Patient SAYS how they feel

 TYPES AND SOURCES OF DATA

       

Objective Data

• Also called overt data

• Gathered through physical assessment and laboratory/diagnostic tests

• Can be observed or measured

• Examples:

  • Vital signs

  • Urine output

  • Wound appearance

  • Laboratory results

what you SEE, HEAR, TOUCH, SMELL, or MEASURE

 PRIMARY vs. SECONDARY SOURCES

Primary Source

• The client/patient

• • Information comes directly from the patient

 = patient

 PRIMARY vs. SECONDARY SOURCES

Secondary Sources

• Everyone/everything else

• Examples:

  • Family

  • Medical record/chart

  • Other healthcare providers

• • Transfer reports

 = everybody/everything else

 NURSING ASSESSMENT SKILL

Observation

• Deliberate use of all senses

• • Gather and interpret information about the patient and environment

 NURSING ASSESSMENT SKILL

Physical Assessment

Produces primarily objective data.

Highlight the five techniques:

1. Inspection = looking

2. Palpation = touching

3. Percussion = tapping

4. Direct auscultation = listening with unaided ear

• 5. Indirect auscultation = listening with a stethoscope

 HELP! Mnemonic for Systematic Observing

H — 

 Help

Look for signs of distress:

• Pain

• Pallor

• • Labored breathing

 HELP! Mnemonic for Systematic Observing

E —

Environment & equipment

Look for:

• Safety hazards

• Machines and lines

• IVs

• Oxygen

• Catheter drainage

• • Make sure equipment is working

 HELP! Mnemonic for Systematic Observing

L — 

Look

Examine the patient:

• Appearance

• Breathing

• Dressings

• • Odors

 HELP! Mnemonic for Systematic Observing

P — 

People

Who is in the room?

• Family

• Caregivers

• • Others

TYPES OF ASSESSMENT

can be broad/general or specific, depending on the client’s status.

Comprehensive Assessment

• Broad

• Holistic information

• Overall health status

• Identifies problems and strengths

• Includes things like:

  • Physical assessment

  • Interviewing

Focused Assessment

• Focuses on a particular problem/topic

• Used for a specific concern

• Examples:

  • Pain

  • Nutrition

  • Functional ability

Initial Assessment

• Completed when patient first comes to the healthcare agency

• Establishes the initial database

• Data relate to the reason for seeking care

= first database

Ongoing Assessment

• Performed as needed after the initial database

• Helps:

  • Identify new problems

  • Follow up on previously identified problems

  • Monitor changes in the patient’s condition

= repeated/updated assessment

Special Needs Assessment

• A type of focused assessment

• Provides in-depth information about a particular area

• May use a specially designed form

• Examples include special assessments such as nutrition status

SPECIAL NEEDS ASSESSMENTS

• Nutritional assessment →

• evaluates nutritional status

• 
  

• Pain assessment →

• evaluates pain

• Cultural assessment →

• identifies cultural influences

• Spiritual health assessment →

• assesses spirituality/spiritual health

• Psychosocial assessment →

• family, lifestyle, personality, relationships, social factors

• Wellness assessment →

• overall wellness, including physical/mental/social areas

• Family assessment →

• family-related health values, beliefs, behaviors

• 
  

• Community assessment →

• community demographics, health concerns, resources, risk

• Functional ability assessment →

• evaluates functional status and ability to perform activities

INTERVIEWING TO OBTAIN A NURSING HEALTH HISTORY

A nursing interview is purposeful and structured.

INTERVIEWING TO OBTAIN A NURSING HEALTH HISTORY

Purpose:

• Gather subjective data

• Obtain information for the nursing database

• Establish a relationship with the patient

INTERVIEWING TO OBTAIN A NURSING HEALTH HISTORY

Important health-history areas:

• Biographical data

• Chief complaint

• History of present illness

• Patient’s perception of health status

• Past health history

• Family history

• Social history

• Medication history/device use

• Complementary/alternative medicine

• • Review of body systems and functional abilities

Directive Interview

• Nurse controls the topics

• Uses mostly closed-ended questions

• Obtains factual/categorized information

• Useful in an emergency situation

 = nurse directs

Nondirective Interview

• Patient controls the subject matter

• Uses mostly open-ended questions

• Promotes communication

• Facilitates thought

• Allows patient to express feelings

 = patient leads

CLOSED-ENDED QUESTIONS

• Answered with yes/no or short factual answers

• Often begin with:

  • Who

  • When

  • Where

  • What

  • Did

  • Is/Are

• • Was/Were

 OPEN-ENDED QUESTIONS

• Allow the patient to explore a topic broadly

• Encourage the patient to elaborate

• Help obtain more detailed information

Example idea:

• Instead of: “Does your chest hurt?”

• Ask: “Tell me about your chest discomfort.”

 HOW AND WHEN SHOULD I VALIDATE DATA?

Validating data = double-checking information to make sure it is accurate, complete, and factual.

Validate when:

• Subjective and objective data don’t agree

• Patient’s statements differ at different times

• Data fall far outside the normal range

Ways to validate:

• Ask additional questions

• Repeat the assessment

• Compare with the other side

• Compare with previous chart entries

• Ask another nurse/provider to double-check when appropriate

= DOUBLE-CHECK

HOW CAN I ORGANIZE DATA?

• Use systematic data collection

• Agencies may organize assessment data according to their framework

• Maslow’s Hierarchy of Needs can help organize data and prioritize problems

⭐ Remember Maslow is used to help determine priorities.

HOW SHOULD I DOCUMENT DATA?

⭐ Documentation must be:

• Complete

• Accurate

• Timely

Why documentation matters:

• Provides the basis for planning effective nursing care

• Protects the nurse by showing that assessments were actually performed

• Becomes part of the legal medical record

If it wasn’t documented, it wasn’t done — legally, you need to be able to show what you assessed/did.

 GUIDELINES FOR RECORDING ASSESSMENT DATA

• Document as soon as possible

• Write neatly/legibly

• Use black ink when handwritten

• Record electronically when appropriate

• Use proper spelling and grammar

• Use abbreviations sparingly

• Write the patient’s own words when possible

• Record only the most important information

• Use concrete, specific information

• Record cues, not inferences

⭐ CUES ≠ INFERENCES

Example:

Cue: “Incision red, draining pus, edges separated.”

Inference: “Incision is infected.”

The nurse should document what was observed, rather than presenting an interpretation as a fact.

TOOLS FOR RECORDING ASSESSMENT DATA

• Graphic flow sheet

• Intake and output (I&O) sheet

• Admission assessment

• Initial discharge summary

• Special-purpose forms

• Electronic documentation

Know what these are generally used for rather than memorizing every detail.

NURSING DIAGNOSIS: THE SECOND STEP OF THE NURSING PROCESS

Diagnosis is the phase where the nurse uses critical-thinking skills to analyze assessment cues and draw conclusions about the client’s health status.

The nurse identifies:

• Strengths

• Problems

• Factors contributing to problems

🧠 Assessment gives you the data → Diagnosis analyzes the data.

 RECOGNIZING WHEN TO USE NURSING DIAGNOSES

Health problem

A condition requiring intervention to:

• Promote wellness

• Treat illness

• • Prevent problems

RECOGNIZING WHEN TO USE NURSING DIAGNOSES

Nursing diagnosis

A statement of the client’s health status that nurses can identify, prevent, or treat independently.

are stated in terms of human responses.

Examples of human responses:

• Anxiety

• Impaired mobility

• Fluid imbalance

• • Fear

 NURSING DIAGNOSIS vs. MEDICAL DIAGNOSIS

Nursing Diagnosis

disease/pathology

• Focuses on human responses

• Can be addressed through nursing interventions

• • Nurses can identify/manage it independently

NURSING DIAGNOSIS vs. MEDICAL DIAGNOSIS

Medical Diagnosis

• Describes a disease, illness, injury, or pathology

• Identifies the medical condition

• Treatment is directed at the disease/pathology

🧠 NURSING = patient’s response

RECOGNIZING COLLABORATIVE PROBLEMS

Collaborative problems are certain physiological complications that nurses monitor to detect changes.

 RECOGNIZING COLLABORATIVE PROBLEMS

They involve:

• Nursing

• Physician/provider

• • Other healthcare professionals

• Potential complication →

 collaborative problem

• If the complication becomes an actual problem/medical diagnosis, it is treated as a medical diagnosis.

If the nurse can prevent/manage the problem with independent nursing interventions, it is NOT a collaborative problem.

ORIGINS OF NURSING DIAGNOSIS

• 1973: First National Conference on the Classification of Nursing Diagnoses

• ANA included nursing diagnosis in its standards

• 1980: ANA published Nursing’s Social Policy Statement

• NANDA International (NANDA-I) continues developing/reviewing nursing diagnoses

⭐ NANDA-I = major organization associated with nursing diagnoses.

• Actual nursing diagnosis →

• a problem that currently exists

• Risk nursing diagnosis →

• a problem that could develop because risk factors are present.

• Possible nursing diagnosis →

• suspected problem that needs more data to confirm.

• Syndrome nursing diagnosis

→ a cluster of nursing diagnoses that commonly occur together.

• Wellness nursing diagnosis →

• describes a person/family/community moving toward a higher level of wellness.

A nursing diagnosis is

different from a medical diagnosis because it focuses on the patient's responses to health problems, rather than identifying the disease itself.

Diagnostic reasoning is the

thinking process used to make sense of patient assessment information and determine the patient's health problems.

You use it to:

• Analyze assessment data.

• Identify important cues.

• Group related cues.

• Identify problems.

• Determine causes/etiologies.

• Verify problems with the patient.

• Prioritize problems.

• • Write diagnostic statements.

Analyze and Interpret Data (diagnostic reasoning)

You narrow assessment data down to the information that is actually important.

⭐ Three major steps diagnostic reasoning :

1. Identify significant cues

2. Cluster cues

• 3. Identify data gaps and inconsistencies

Step 1: Identify Significant Cues

A cue is information that gives you a clue about a patient's health status.

Significant cues can include:

• Abnormal vital signs

• Abnormal assessment findings

• Patient statements

• Changes from the patient's normal condition

• Signs/symptoms

• Relevant laboratory or diagnostic results

Pay attention to changes, abnormalities, and information that relates to the patient's health problem.

Step 2: Cluster Cues

is a group of cues that are related in some way.

Related cues can point toward the same nursing problem.

Example:

• Incontinence

• Frequent urgency

• Difficulty getting to bathroom

⬇

These may cluster around a self-care/mobility problem.

Step 3: Identify Data Gaps and Inconsistencies

Data gaps

Missing information needed to make an accurate diagnosis.

Inconsistencies

When subjective and objective information do not agree.

Example:

• Patient says, “I have no pain.”

• Patient is grimacing and guarding an area.

Do NOT make assumptions when information is missing or contradictory. Gather more data.

Draw Conclusions About Health Status

After clustering cues:

• Determine what the cues mean.

• Identify possible health problems.

• Identify possible causes.

• Decide what type of nursing diagnosis may apply.

 Make Inferences

Fact

Something you can directly observe or verify.

Example:

• Patient is crying.

• Patient is trembling.

Inference

A conclusion you draw from facts.

Example:

• Patient may be experiencing anxiety.

⭐ Important

An inference is not automatically a fact. You need enough evidence to support it.

Verify Problems With the Patient

Before finalizing a diagnosis:

• Check your interpretation with the patient.

• Ask questions.

• Make sure your interpretation matches the patient's experience.

• Do not rely only on your own assumptions.

⭐ Key Point

The patient is the best source for verifying many subjective problems.

Prioritize Problems

You cannot always address every problem at once.

Prioritize based on:

1. Urgency

2. Safety

3. Basic/physiological needs

4. Potential consequences

5. Patient preferences

⭐ Important

A problem that threatens life, airway, breathing, circulation, or safety generally receives higher priority.

Labeling Each Problem

After identifying and verifying the problem, give it an appropriate nursing diagnostic label.

Problem Urgency

Problems can be ranked from:

• High priority

• Medium priority

• • Low priority

⭐ Key Point

The most urgent problems should be addressed first.

Focused Ability Assessment

ask whether the patient can independently perform activities such as:

• Mobility

• Transfers

• Feeding

• Bathing

• Dressing

• Toileting

• Moving around safely

⭐ Important

If a patient cannot perform an activity independently, determine why and what assistance is needed.

Medical Diagnosis

Identifies a disease/pathology.

Example:

• Chronic renal failure

• • Type 2 diabetes

Collaborative Problem

A potential complication that nurses monitor and manage collaboratively with other healthcare providers.

⭐ Key Point

The nurse does not independently diagnose or treat the medical condition.

Actual Nursing Diagnosis

A problem that currently exists.

Requires:

• Signs/symptoms

• • Defining characteristics

Risk Nursing Diagnosis

A problem that has not occurred yet, but the patient has risk factors.

⭐ Important

A risk diagnosis has risk factors, but no actual signs/symptoms of the problem yet.

Syndrome Nursing Diagnosis

A cluster of nursing diagnoses that tend to occur together.

Patient Strengths

Positive abilities/resources the patient possesses.

Examples:

• Family support

• Motivation

• Ability to learn

• Coping abilities

Wellness Nursing Diagnosis

Used when a patient is moving toward a higher level of wellness.

Future Consequences

When assigning priority, consider what could happen if a problem is not treated.

⭐ Important

A problem may not be immediately dangerous but could have serious future consequences.

Patient Preference

Patient preferences matter when prioritizing.

⭐ Key Point

Patients are more likely to cooperate with interventions when their concerns and priorities are considered.

However, patient preference cannot override urgent safety or life-threatening needs.

Computer-Assisted Diagnosing

Computer systems can help nurses:

• Organize assessment data.

• Identify possible diagnoses.

• Compare characteristics of problems.

• Suggest possible diagnostic labels.

⭐ Important

Computer systems are a tool. The nurse still has to use clinical judgment and verify the diagnosis.

REFLECTING CRITICALLY ON YOUR DIAGNOSTIC REASONING

After forming diagnoses, ask yourself:

• Did I collect enough information?

• Did I interpret the cues correctly?

• Did I consider other explanations?

• Did I prioritize correctly?

• • Did I let assumptions affect my thinking?

Think About Your Self-Knowledge

Your own:

• Beliefs

• Experiences

• Expectations

• Biases

• Assumptions

can influence how you interpret patient data.

What Biases and Stereotypes May Have Influenced My Interpretation of the Data?

Bias

A tendency to make judgments based on personal opinions or expectations.

What Biases and Stereotypes May Have Influenced My Interpretation of the Data?

Stereotype

A generalized belief about a group of people.

⭐ Important

Do not allow stereotypes to replace individual patient assessment.

Did I Rely Too Much on Past Experiences?

Past experiences can help, but:

⭐ Do NOT assume

that because two patients look similar, they have the same problem.

Each patient needs to be assessed individually.

Did I Rely Too Much on the Client's Setting, or What Others Say About the Client?

Do not allow:

• Location

• Other people's opinions

• Previous labels

• Stereotypes

to replace your own assessment of the patient.

⭐ Key Point

Base your diagnosis on the patient's actual data.

Critiquing Your Diagnostic Reasoning Process

Data Analysis

Ask:

• Did I identify significant cues?

• Did I identify important cues from the cluster?

• Did I throw away unnecessary/confusing information?

• Did I consider more than one grouping of cues?

• Did I consider cultural/spiritual beliefs?

Critiquing Your Diagnostic Reasoning Process

Drawing Inferences

Ask:

• Did I consider all possible explanations?

• Is this the best explanation?

• Did I look for patterns?

• Did I avoid jumping to conclusions?

Critiquing Your Diagnostic Reasoning Process

Critiquing the Diagnostic Statement

Ask:

• Is the diagnosis relevant?

• Does it reflect the patient's problem?

• Is the etiology accurate?

• Does the diagnosis clearly describe the patient's status?

Critiquing Your Diagnostic Reasoning Process

Verifying the Diagnosis

Ask:

• Did the patient verify the diagnosis?

• Did the patient understand my description?

• Did I get feedback?

Critiquing Your Diagnostic Reasoning Process

Prioritizing

Ask:

• What problems are most important?

• Which require immediate attention?

• Did I consider patient preferences?

STANDARDIZED NURSING LANGUAGES

Standardized nursing language:

• Uses consistent terminology.

• Supports electronic health records.

• Helps nurses communicate.

• Helps expand nursing knowledge.

⭐ Important

Standardized language makes documentation and communication more consistent.

 NURSING DIAGNOSES

Classification Systems Used in Healthcare

Major classification systems discussed: