Nursing Fundamentals: The Nursing Process and Assessment
Introduction to the Nursing Process
The primary goal of the nursing process is to help individuals meet their basic and higher-level needs.
This process leads to specific interactions, including communication, observation, support, education, and the provision of care.
Nurses support and encourage others in maintaining healthy habits and help solve health problems by combining scientific problem-solving methods with critical thinking skills.
Problem-Solving Methods
Trial and Error:
An experimental approach that tests ideas to determine which methods work and which do not.
It is often used when there is insufficient information to anticipate results.
While common in laboratory studies, it must be used very carefully with people due to possible harmful results.
The use of trial and error requires strict guidelines to protect the safety and well-being of individuals.
Scientific Problem-Solving:
Identify the problem.
Gather information relative to the problem.
Formulate tentative solutions (hypotheses) and choose a preferred solution.
Plan action to test the suggested solution.
Experiment and observe the results.
Interpret the results (draw conclusions) to understand their meaning.
Evaluate the solution, either concluding the study or revising it to test the solution again if results are unsatisfactory.
Critical Thinking in Nursing
Critical thinking involves grasping the meaning of multiple clues and finding quick answers when facing difficult problems.
It is a unique system that is distinct from both trial-and-error and structured scientific problem-solving.
Nurses examine facts and compare them with known information.
It requires being actively curious and critiquing ideas for reasonableness.
Nurses use it to form concepts that serve as mental pictures of reality, recognizing that most client care problems have multiple possible causes and solutions.
The Nursing Process Framework
The nursing process combines critical thinking skills with scientific problem-solving to identify client problems and provide care in a structured, purposeful, and effective way.
It is a systematic method directing the nurse and client as they work together to:
Determine the need for nursing care.
Plan and implement the care.
Evaluate the results.
Nurses and clients work as partners to promote health, prevent disease/illness, restore health, and facilitate coping with altered functioning.
Practical tools within this process include:
Nursing Care Plan (NCP).
Critical pathways.
Concept mapping.
Clinical pathways.
A care plan helps manage time effectively and determines if the nursing care provided actually helped the client.
The process allows nurses to address potential needs or problems before they develop.
Professional Roles and Regulations
Use of the nursing process varies across the United States and Canada, different healthcare facilities, and the differing roles of the Registered Nurse (RN) and Licensed Vocational/Practical Nurse (LV/LPN).
Nurses must function within their professional role based on facility licensure, specific responsibilities, and mandated regulations from the Board of Nursing.
Practitioners must be familiar with the Nurse Practice Act and local regulations for their specific location and situation.
The nursing process highlights the difference between licensed and unlicensed personnel. While unlicensed personnel might know how to perform a task (e.g., taking vital signs), the licensed nurse must know why the task is important and understand the relationship between the data obtained and the client's condition.
Characteristics of the Nursing Process
Systematic: Follows specific, orderly, and logical steps based on the client’s most important or vital needs through prioritization.
Client-oriented: Identifies the needs of the client specifically, rather than the needs of the nurse, family, or other providers. Focuses on individualized care.
Goal-oriented: Establishes short-term and long-term goals, objectives, or expected outcomes early in the process.
Continuous: Reassessment is performed frequently due to changes, allowing for constant revision.
Dynamic: Steps often overlap as the nurse develops the ability to use critical thinking skills fluently.
Communication: Serves as a method of communication through documentation, indicating the effectiveness and quality of care.
Mapping Scientific Problem-Solving to the Nursing Process
Gather Information: Nursing Assessment.
Identify Problem: Nursing Diagnosis.
Formulate/Choose Solutions: Planning.
Test Solutions: Implementation (Interventions).
Evaluate Results: Evaluation.
Revise as Conditions Change: Review, Reevaluate, Revise, and Repeat.
Nursing Assessment
Assessment is the first step of the nursing process; all subsequent steps depend on complete and accurate information (data).
It begins as soon as the nurse-client relationship is established.
The process involves the systematic and continuous collection and analysis of information about the client, organized into a specific format.
Key components of Assessment:
Identifying priorities.
Collecting data through observation, interview, and physical examination.
Continuously updating the database.
Analyzing data by recognizing significant signs, validating observations, recognizing patterns/clusters, and identifying strengths and problems.
Data Collection Types
Objective Data:
Measurable and observable pieces of information.
Utilizes precise, accurate measurements or quantifiable descriptions.
Examples include vital signs, laboratory results, radiology reports, and physical examination findings.
Does not include judgments, opinions, or client statements.
Subjective Data:
The client’s opinions or feelings about what is happening.
Communicated through spoken words, written words, and body language.
Requires sharp interviewing, listening, and observation skills.
Includes consideration of cultural factors, beliefs, amulets, or folk remedies.
Methods of Data Collection
Observation:
Visual: Noting body movements, appearance, mannerisms, facial expressions, mode of dress, nonverbal communication, interaction with others, skin color, and cleanliness. Skin inspection for rashes is objective; noting facial expressions for mood is subjective.
Tactile: Using palpation to assess muscle strength, temperature, moisture, edema, rashes, or swelling.
Auditory: Active listening to the client and family; use of specialized equipment for auscultation.
Olfactory/Gustatory: Identifying specific odors related to conditions, such as microorganisms, body/breath odors, alcohol, or metabolic acidosis.
The Health Interview:
Nursing History: Soliciting information from the client using facility-specific forms.
Admission Interview: Conducted upon entry to the facility.
Communication Methods: Using open-ended questions for broad info and closed-ended questions for specific details.
Components: Biographical data, reason for visit, recent health history, medical history, psychosocial info, and Activities of Daily Living (ADLs).
Confidentiality: Mandatory adherence to HIPAA; client permission is required to share information with anyone, including family members.
Data Analysis and Reaching Conclusions
Validation: Nurses must "check out" observations with the client. The client is considered the "team leader."
Recognizing Patterns (Clusters): Identifying symptoms that occur at particular times (e.g., after eating, walking, or at night) and grouping them for analysis.
Identifying Strengths: Looking for client assets that can be used to cope with health problems.
Types of Conclusions:
No problem: No further nursing care needed; reinforce current habits.
Potential problem: Indicates the client is at risk; requires planning, implementation, and evaluation.
Clinical problem: Results in a nursing diagnosis (which nursing staff may treat independently) or a medical diagnosis (which requires consultation and collaboration with a physician).
Questions & Discussion
Question 1 Is the following statement true or false? Trial-and-error experimentation can be done only with the permission and understanding of the individual involved. Answer: True. Trial and error must be used carefully when working with people because of the possible harmful results. Researchers develop strict guidelines to protect the safety and well-being of individuals and proceed with experimentation only with the permission of the individual involved.
Question 2 Is the following statement true or false? The nursing process highlights the differences in roles between licensed personnel and nonlicensed personnel. Answer: True. The nursing process not only includes the actions involved in tasks but also integrates critical thinking. Unlicensed personnel are required to know how to take vital signs. In addition to how, the licensed nurse must also know why the vital signs are important and what is the relationship of the numbers obtained with the condition of the client.
Question 3 Which step of the nursing process allows the nurse to identify priorities and collect data? a. Nursing assessment b. Nursing diagnosis c. Planning d. Implementation e. Evaluation Answer: a. Nursing assessment. The nurse identifies priorities, collects data, and updates the database during the assessment phase of the nursing process.
Question 4 Is the following statement true or false? The client complains of a headache and fever; however, she has not recorded the temperature. This is an example of subjective data. Answer: True. This data is subjective because it is based on the client's feelings. If the temperature is measured by a thermometer, then that data would be objective.
Question 5 Is the following statement true or false? A 15-year-old client who is experiencing lower abdominal cramps admits that she has had an abortion in the recent past, of which her family has no knowledge. The nurse is required to inform her parents as she is under age. Answer: False. The nurse must protect the confidentiality of the client, never revealing any information previously unknown to the family without the client’s permission.
Question 6 Is the following statement true or false? A medical diagnosis falls in the domain of nursing, and nursing staff may treat it without consulting a physician. Answer: False. A medical diagnosis is determined by the physician and is a collaborative problem; the nursing staff must consult a physician and work together to resolve the problem. A nursing diagnosis falls in the domain of nursing, and nursing staff may treat it without consulting a physician.