FUN Chapter 2

Overview and Objectives of the Nursing Process

• Definition: An organized sequence of problem-solving steps used to identify and manage the health problems of clients.

• Core Outcomes: When executed correctly, clients receive quality care in minimal time with maximal efficiency. It provides the legal and professional basis for determining whether standards of care have been met.

• Learning Objectives:

  • Explain the nursing process definition, unique characteristics, and sequential steps.

  • Analyze assessment and data collection methods, including data sources and structural differences among database, focused, and functional assessments.

  • Differentiate clinical decision-making components, including nursing diagnoses versus collaborative problems, and the structural formatting of diagnostic statements.

  • Develop and prioritize plans of care, including setting appropriate short-term and long-term goals and applying rationales for clinical prioritization.

Ethical Principles in Nursing Practice

• Beneficence: "Doing good" or acting directly for another's benefit by preventing or removing potentially harmful factors.

• Nonmaleficence: "Doing no harm" or deliberately avoiding any action that causes harm to a person.

• Autonomy: The explicit right of a competent client to make their own decisions without intimidation, coercion, or external influence.

• Veracity: The moral and professional duty to be honest and avoid deceiving or misleading a client.

• Fidelity: Being faithful to work-related commitments, duties, and professional obligations (e.g., maintaining Continuing Education Units [CEUs], keeping certifications active such as BLS, ALS, PALS, and adhering strictly to HIPAA guidelines).

• Justice: The mandate that clients are treated impartially without discrimination based on age, gender, race, religion, socioeconomic status, weight, marital status, or sexual orientation.

Scope of Practice and Responsibilities: LPN vs. RN

• Assessing:

  • Licensed Practical Nurse (LPN): Gathers information and data on stable clients.

  • Registered Nurse (RN): Collects comprehensive data on complex or unstable cases.

• Diagnosing:

  • LPN: Identifies and reports abnormal data to the healthcare team.

  • RN: Analyzes data and utilizes standardized classification lists to formulate formal nursing diagnostic statements.

• Planning:

  • LPN: Assists in establishing realistic goals and suggests potential nursing actions.

  • RN: Sets realistic, measurable goals and independently develops the comprehensive written plan of care.

• Implementing:

  • LPN: Performs basic nursing care interventions under the direct direction and supervision of an RN.

  • RN: Identifies clinical priorities and directs other team members to carry out prescribed nursing orders.

• Evaluating:

  • LPN: Shares ongoing observations regarding client progress and contributes observations toward care plan revisions.

  • RN: Routinely evaluates client outcomes against established goals and makes formal revisions to the plan of care.

Interprofessional Roles: Nursing vs. Medicine

• Nursing Discipline Expertise:

  • Screening high-risk individuals, families, and communities, and teaching health prevention strategies.

  • Diagnosis and management of complex altered functional responses in individuals, families, and communities.

  • Utilization of diverse intervention modalities (e.g., counseling, patient teaching, self-help techniques, non-traditional therapies, health negotiation).

  • Management of refractive health problems.

• Shared Expertise (Overlap between Nursing and Medicine):

  • Primary, secondary, and tertiary prevention practices.

  • Conducting patient interviews, taking health histories, and performing physical assessments.

  • Diagnosing acute and chronic medical problems.

  • Using prescriptions, direct interventions, and patient instruction to manage uncomplicated acute and chronic medical conditions.

  • Initiating interprofessional consultations when clinically appropriate.

• Medicine Discipline Expertise:

  • Differential diagnosis of complex medical problems.

  • Management of refractive acute medical conditions.

  • Management of multisystem diseases associated with high morbidity or mortality.

The Five Sequential Steps of the Nursing Process (ADPIE)

• 1. Assessment (A): Systematically collect, organize, and document client data.

• 2. Diagnosis (D): Analyze collected data to identify formal nursing diagnoses and collaborative problems.

• 3. Planning (P): Prioritize client problems, establish measurable outcome criteria (goals), select evidence-based nursing interventions, and document the formal plan of care.

• 4. Implementation (I): Carry out planned nursing orders and execute medical orders while documenting provided care and client responses.

• 5. Evaluation (E): Monitor client outcome attainment, and determine whether to resolve, continue, or revise the current care plan.

Step 1: Assessment and Data Collection

• Data Types:

  • Objective Data: Observable and measurable facts, technically referred to as signs of a disorder.

    • Examples: Vital signs, height, weight, skin color and temperature, laboratory values, observed vomiting, active bleeding, an incisional scar in the right lower quadrant, an irregular heart rate, blood pressure reading of $166/86\text{ mmHg}$, pupils equal, round, reactive to light and accommodation (PERRLA), or staff observations of gait alterations.

  • Subjective Data: Information that only the client can feel, experience, and describe, technically referred to as symptoms.

    • Examples: Pain ratings (e.g., rating pain as $8$ on a scale of $10$), nausea, mental health distress, feelings of loneliness, fatigue, client statements of feeling rested, or statements regarding family discomfort.

• Sources of Data:

  • Primary Source: The client.

  • Secondary Sources: Family members, medical records/charts, diagnostic test results, reports, and interprofessional consultations.

• Assessment Classifications:

  • Database Assessment:

    • Timing: Performed upon admission only.

    • Method: Standardized predetermined questions paired with a systematic, comprehensive head-to-toe physical examination.

    • Purpose: Establishes baseline data reflecting client condition entering the system, suggests potential problems, and provides breadth for future comparison.

    • Duration/Scope: Time-consuming; may require $1+\text{ hours}$ to complete.

  • Focused Assessment:

    • Timing: Repeated every shift, as needed (PRN), or during acute condition changes.

    • Method: Targeted physical assessments paired with unstructured questions.

    • Purpose: Confirms or rules out specific problems, adds depth to database assessment, and tracks trends in response to interventions.

    • Duration/Scope: Brief; typically completed in approximately $15\text{ min}$.

  • Functional Assessment:

    • Timing: Completed within $14\text{ days}$ of admission, reviewed every $3\text{ months}$, and re-evaluated fully every $12\text{ months}$.

    • Method: Interdisciplinary evaluation of physical, cognitive, and social performance capabilities.

    • Purpose: Evaluates current functional strengths and potential to avoid functional decline; serves as a facility quality indicator.

    • Duration/Scope: Labor-intensive interdisciplinary effort.

Step 2: Nursing Diagnosis

• Core Concepts:

  • Definition: Analysis of collected assessment data to identify health-related problems.

  • Nursing Diagnosis Scope: Addresses health issues that can be prevented, reduced, resolved, or enhanced specifically through independent nursing measures.

  • Prioritization Order: Actual active problems always take clinical priority over potential or "risk for" problems.

• Categories of Nursing Diagnoses:

  • Problem-Focused Diagnosis: Identifies an existing health problem present at the time of assessment.

    • Example: Impaired gas exchange related to abnormal blood gases and respiratory diagnosis.

  • Risk Diagnosis: Identifies clinical conditions that the client is uniquely vulnerable to developing.

    • Examples: Risk for infection related to potential infection from injury or surgery; Risk for falls related to orthostatic hypotension.

  • Syndrome Diagnosis: Comprises a cluster of individual nursing diagnoses occurring together due to a specific event or situation, managed via similar interventions.

    • Examples: Disuse syndrome, deconditioning, or bathing/hygiene ADL deficits.

  • Health Promotion Diagnosis: Clinical judgment regarding a healthy individual's motivation and desire to increase well-being and achieve higher wellness levels.

    • Example: Readiness for enhanced health management / altered health maintenance.

• Structure of a Problem-Focused Diagnostic Statement (PES Format):

  • 1. Problem ($P$): Diagnostic label defining the health issue.

  • 2. Etiology ($E$): Underlying cause or contributing factors, connected using the phrase "related to" ($\text{r/t}$).

  • 3. Signs & Symptoms ($S$): Defining characteristics or evidence derived from assessment, connected using the phrase "as evidenced by" ($\text{AEB}$).

Step 3: Planning and Goal Development

• Prioritization Frameworks:

  • Maslow's Hierarchy of Human Needs (Formulated by psychologist Abraham Harold Maslow [April 1, 1908 – June 8, 1970], published in 1954 in Motivation and Personality): Identifies that lower basic physiological needs must be satisfied before higher-tier psychological needs can be met.

    • 1. Physiological Needs (Highest Priority / ABCs): Oxygenation, breathing, food, water, sleep, sex, homeostasis, excretion.

    • 2. Safety and Security: Physical security of body, employment, resources, morality, family, health, property.

    • 3. Love and Belonging: Friendship, family, intimacy, social connection.

    • 4. Esteem: Self-esteem, confidence, achievement, mutual respect.

    • 5. Self-Actualization: Reaching full human potential, morality, creativity, spontaneity, problem-solving, lack of prejudice, acceptance of facts.

  • Prioritization Rules in Clinical Nursing:

    • Physiologic needs (Airway, Breathing, Circulation) supersede non-physiologic needs.

    • Acute issues supersede chronic issues.

    • Unstable clients supersede stable clients.

    • Unexpected clinical findings supersede expected findings.

    • Actual active problems supersede "Risk for" potential problems.

• Establishing Outcomes and Goals:

  • Short-Term Goals:

    • Timeframe: Achievable in a few days to $1\text{ week}$.

    • Required Characteristics: Must be client-centered (formatted as "Client will…"), measurable, realistic, and contain an explicit target completion date.

  • Long-Term Goals:

    • Timeframe: Takes weeks or months to accomplish.

    • Application: Designed for clients with chronic conditions requiring extended care, long-term care facility residents, or home health care recipients.

  • Collaborative Goals:

    • Written from a nursing perspective detailing actions nurses execute to monitor, report, record, or treat medical problems early (e.g., "Nurse will administer prescribed medications as ordered," or "LPN will monitor for and report vital sign abnormalities to the physician").

• Selecting Nursing Interventions:

  • Requires critical thinking—analyzing, interpreting, and evaluating clinical data objectively.

  • Interventions must be safe, within legal scope of nursing practice, and compatible with established medical orders.

• Communicating the Care Plan:

  • Shared among team members, client, and family.

  • Serves as a permanent part of the legal medical record that is consulted daily, evaluated regularly, and modified as client condition evolves.

Step 4: Implementation

• Execution: The practical action phase where the written plan of care is initiated.

• Scope: Includes executing both nursing orders and medical orders, which work synergistically.

• Documentation Requirements: The medical record acts as legal evidence verifying that orders were carried out while quantifying and qualifying client responses.

Step 5: Evaluation

• Process: Systematically assessing client responses to interventions to determine whether targeted outcomes and goals have been achieved.

• Clinical Outcomes: Based on evaluation findings, care plans are either resolved (if goals are fully met), continued, or formally revised with altered goals or new interventions.

Comprehensive Case Study: Client Scenario (Freda)

• Initial Profile: Freda, a $30\text{-year-old}$ female, presents with severe stress regarding nursing school, voicing fears that she will "probably flunk out." She continuously refreshes her online gradebook during class and experiences severe anxiety preventing lecture focus.

• Assessment Phase Data Collection:

  • Subjective Data: Reports feeling tense, overwhelmed, unable to sleep at night, nauseated for the past $2\text{ weeks}$, experiencing a $10\text{ lb}$ weight loss, and compulsively biting her nails.

  • Objective Data: Observed wringing hands in her lap, facial flushing, unkempt/uneven fingernails, active nail-biting during interview. Vital signs: Heart Rate $110\text{ bpm}$ (elevated), Blood Pressure $140/90\text{ mmHg}$ (elevated), Respiratory Rate $20\text{ breaths/min}$, Temperature $98.6\,^{\circ}\text{F}$, Pain rating $0/10$

• Diagnostic Phase Formulations:

  • Problem ($P$): Anxiety

  • Etiology ($E$): Stressors (nursing school coursework)

  • Signs & Symptoms ($S$): Altered sleep patterns, increased physical tension, elevated blood pressure and heart rate, apprehension, and emotional distress.

  • Complete PES Statement: Anxiety $\text{r/t}$ stressors $\text{AEB}$ alteration in sleep pattern, increased tension, change in blood pressure and heart rate, apprehensive, distressed.

• Planning Phase Commitments:

  • Target Goal: Client will appear relaxed and report anxiety is reduced to a manageable level within $2\text{ weeks}$.

  • Selected Interventions:

    1. RN will evaluate coping mechanisms and defense mechanisms utilized to handle perceived threats.

    2. LPN will assist client in identifying controllable versus uncontrollable personal factors.

    3. LPN will instruct client on positive self-talk strategies.

    4. LPN will encourage development of a regular physical exercise program.

    5. LPN will instruct in guided imagery and relaxation modalities (pleasant visualization, music therapy, deep breathing, meditation, mindfulness).

• Evaluation Phase ($2\text{-Week}$ Follow-Up):

  • Clinical Findings: Client sits upright with open posture and smiles. Reports reduced tension, improved academic performance/grades, routine physical exercise using video guides $3\times/\text{week}$, nightly meditation, and ongoing counseling visits.

  • Re-assessed Vital Signs: Heart Rate $70\text{ bpm}$, Blood Pressure $118/72\text{ mmHg}$, Respiratory Rate $14\text{ breaths/min}$, Temperature $98.6\,^{\circ}\text{F}$, Pain rating $0/10$

  • Status: Goal successfully met; problem resolved.

Practice Questions and Applied Rationales

• Question 1: By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

  • Option A: Reassess the client to determine the reasons for inadequate pain relief

  • Option B: Wait to see whether the pain lessens during the next $24\text{ hr}$

  • Option C: Change the plan of care to provide different pain relief interventions

  • Option D: Teach the client about the plan of care for managing the pain

  • Answer: Option A

  • Rationale: Nurses must always reassess before intervening. Assessment gathers data required to select appropriate, effective revised interventions.

• Question 2: A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was $6\text{ hr}$ ago. The prescription reads every $4\text{ hr}$ PRN for pain. The nurse administered the medication and checked with the client $40\text{ min}$ later, when the client reported improvement. The newly licensed nurse left out which step of the nursing process?

  • Option A: Assessment

  • Option B: Planning

  • Option C: Intervention

  • Option D: Evaluation

  • Answer: Option A

  • Rationale: Pain assessment must occur prior to intervention selection. Proper assessment identifies whether non-pharmacological methods (e.g., repositioning) are viable, and establishes pain location, intensity, quality, duration, and exacerbating/relieving factors.

• Question 3: Which of the following data should the nurse identify as objective data? (Select all that apply)

  • Option A: The client's pupils are PERRLA

  • Option B: The certified nursing assistant (CNA) reports that the client drags the left foot while walking

  • Option C: The client reports feeling nauseous

  • Option D: Regular heart rate $110\text{ bpm}$

  • Option E: The client's aunt states, "Her legs hurt after walking to the bathroom and back to bed."

  • Answer: Options A, B, and D

  • Rationale: Directly observable or measurable physical facts are objective. Statements made by clients or family members regarding internal sensations constitute subjective data.

• Question 4: A nurse has encouraged a bedridden hospital client to perform deep breathing and coughing exercises each hour to prevent respiratory complications. After performing this intervention, the nurse should:

  • Option A: Ensure that the client expresses an understanding of the etiology of pneumonia

  • Option B: Ask the client's family to observe the client's performance of the exercises

  • Option C: Obtain an order for bronchodilators for the client's physician

  • Option D: Assess the client's lungs to determine the effectiveness of the intervention

  • Answer: Option D

  • Rationale: Post-intervention evaluation via lung reassessment is required to determine intervention efficacy and guide ongoing care decisions.