Fundamentals of Nursing: Nursing Process

Nursing Process and Critical Thinking: Fundamentals of Nursing

Definition and Foundations of Nursing

American Nurses Association (ANA) Definition of Nursing

Nursing is defined by the American Nurses Association (ANA) as "the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations."

The Nursing Process

The nursing process is a systematic method by which nurses plan and provide care for patients. It serves as a problem-solving approach consisting of six distinct phases.

The Six Phases of the Nursing Process

Phase 1: Assessment

Assessment occurs upon the first contact with the patient. It involves the collection, documentation, and interpretation of data. The accuracy and completeness of the assessment are critical, as all other phases of the nursing process depend on this step.

Types of Assessment

1. Complete Assessment: Involves a comprehensive review and physical examination of the body systems, including:

   • Musculoskeletal

   • Respiratory

   • Gastrointestinal

   • Cardiac

   • Psychological

   • Genitourinary

   • Emotional

   • Cultural

2. Focused Assessment: Performed when the patient is critically ill, disoriented, or unable to respond. It remains focused on a specific health problem. Examples include:

   • Addressing specific issues like a migraine or low blood sugar.

   • Monitoring continuous patient care indicators such as skin color, skin turgor, and oral mucous membranes.

   • Determining progress toward achieving desired outcomes.

Assessment Data

• Data Types:

  • Cue: A signal or hint of a condition.

  • Subjective Data: Information provided by the patient (e.g., statements about pain or feelings).

  • Objective Data: Observable and measurable signs (e.g., vital signs, physical exam findings).

• Sources of Data:

  • Primary Source: The patient.

  • Secondary Sources: Family members, medical records, diagnostic procedures, and previous nursing progress notes.

• Methods of Data Collection: Interviews and physical examinations.

Phase 2: Patient Problem Statement (Nursing Diagnosis)

A patient problem statement is a type of health problem identified by the nurse. The North American Nursing Diagnosis Association International (NANDA-I) provides the framework for these statements.

Components of a Patient Problem Statement

• The patient’s presenting signs and symptoms.

• Contributing, etiologic (causative), and related factors.

• Defining characteristics.

• Problem statements may be categorized as Actual or Potential.

Example: Constipation

• Nursing Diagnosis: Constipation related to (r/t) insufficient fluid intake as manifested by (AMB) increased abdominal pressure, no bowel movement for $5\,days$, and straining with defecation.

• Title/Label: Constipation.

• Definition: Decrease in normal frequency of defecation.

• Etiology: Insufficient fluid intake.

• Defining Characteristics: Increased abdominal pressure, no BM for $5\,days$, straining.

Other Types of Health Problems

• Collaborative Problems: Complications that nurses monitor to detect onset or changes in status. These are managed using both physician-prescribed and nurse-prescribed interventions (e.g., monitoring for hypoglycemia).

• Medical Diagnosis: Identification of a disease or condition through evaluation of physical signs, symptoms, patient interviews, lab tests, diagnostic procedures, and medical history (e.g., CHF, pneumonia, diabetes mellitus, hepatitis B).

Phase 3: Goal Identification (Outcomes Identification)

A goal statement indicates the degree of wellness desired, expected, or possible for the patient. It provides a description of specific, measurable behavior the patient will exhibit within a certain time frame.

Characteristics of Patient-Centered Goals

• Uses the patient (or a part of the patient) as the subject.

• Uses a measurable verb.

• Is specific to the patient and their specific problem.

• Does not interfere with the medical plan of care.

• Is realistic.

• Includes a specific time frame for reevaluation.

Examples of Outcomes in a Care Plan

• Acute Pain: The patient will verbalize pain relief of $3/10$ from $9/10$ within $30\,min$ of pain medication administration.

• Impaired Skin Integrity: Patient will not develop wound infection during the shift.

• Impaired Gas Exchange: Patient will maintain $O_2$ saturation of $90\%$ to $95\%$ (from $86\%$)) during the shift.

Phase 4: Planning

In this phase, the nurse establishes priorities of care and selects nursing interventions to address the diagnosis. This information is communicated via the care plan to ensure continuity of care among all healthcare personnel.

Priority Setting

The RN prioritizes patient problem statements based on current health status. Hierarchy of priorities:

1. Physiologic Needs: These come before safety and security.

2. Safety and Security: These come before love and belonging.

3. Life- and Health-Threatening Problems: Ranked highest.

4. Actual Problems: Usually ranked before risk (potential) problems.

5. Dynamic Nature: Priorities change as the patient progresses or as problems resolve.

Practice Prioritization (Maslow's Hierarchy)

Based on Maslow's hierarchy, the following diagnoses are ranked by priority, with number 1 being the highest:

1. Ineffective airway clearance

2. Deficient fluid volume

3. Acute pain

4. Stress urinary incontinence

Selecting and Writing Nursing Interventions

Nursing interventions are activities that promote the achievement of desired outcomes. They are classified as:

• Physician-Prescribed: Carrying out a doctor's orders.

• Nurse-Prescribed: Selected by the nurse to resolve a diagnosis or monitor for risk.

• Writing Rules: Interventions must be specific and instructional to reduce misinterpretation. They should include a subject, an action verb, and qualifying details.

Phase 5: Implementation

The nurse and the healthcare team put the plan into action. This phase focuses on using evidence-based interventions in a timely and safe manner.

Implementation Examples

• Administering pain medication as ordered.

• Repositioning the patient.

• Performing proper hand washing.

• Applying aseptic technique in wound management.

• Administering $O_2$ at $4\,L/min$ via nasal cannula (N/C).

• Elevating the head of the bed (HOB) to $30\,degrees$.

Phase 6: Evaluation

Determination of the extent to which patient goals have been achieved. Steps include:

1. Reviewing patient goals/outcomes.

2. Reassessing the patient response to interventions.

3. Comparing actual outcomes with desired outcomes to make a critical judgment.

• Conclusions: The goal was achieved, the goal was not achieved, or the goal was partially achieved.

Standardized Languages and Managed Care Systems

NANDA-I, NIC, and NOC

• NANDA-I: North American Nursing Diagnosis Association International.

• NIC (Nursing Interventions Classification): A standardized language used to organize and describe nursing interventions, developed at the University of Iowa.

• NOC (Nursing Outcomes Classification): A standardized system to name and measure results of patient outcomes, also developed at the University of Iowa.

Clinical Pathways and Managed Care

• Managed Care: A system focusing on primary healthcare services while attempting to trim costs by reducing unnecessary or overlapping services.

• Case Management: Coordination of care and advocacy to provide quality, cost-effective outcomes.

• Clinical Pathways: A multidisciplinary plan incorporating evidence-based guidelines for high-risk, high-volume, and high-cost cases. It coordinates actions from all disciplines.

• Variance: Occurs when a patient does not achieve the projected outcome defined in the clinical pathway. Frequent variances trigger a revision of the pathway.

Professional Roles and Critical Thinking

Role of the LPN/LVN

• The specific role in the nursing process varies by state; nurses must review their state’s Nurse Practice Act.

• The LPN/LVN provides direct bedside care, allowing them to closely observe, prioritize, intervene, and evaluate the patient.

Critical Thinking in Nursing

• Critical thinkers think with a purpose, questioning information, conclusions, and points of view.

• It involves being logical and fair.

• Nurses use a knowledge base to make decisions, solve problems, and generate new ideas. They must not only perform skills but think about what they are doing.

Critical Thinking Scenario

A patient underwent a hemorrhoidectomy $2\,days$ ago. When assigned to check vital signs, you have the choice between an oral and a rectal thermometer.

• Critical Thinking Application: Choosing the oral thermometer over the rectal thermometer because a rectal thermometer could cause trauma, pain, or bleeding at the surgical site of the hemorrhoidectomy.