Chapter 19 COMPONENTS OF THE NURSING PROCESS

OBJECTIVES

• Define the key terms/concepts

• Discuss the steps used in nursing diagnosis and the use of the NANDA approved nursing diagnosis

• Examine the difference between a medical and nursing diagnosis

• Discuss the planning phase and development of nursing care plans

• Provide an overview of the nursing process

• Provide an explanation of the assessment phase, including conducting assessments requiring cultural awareness

KEY TERMS/CONCEPTS

assessment

diagnosis

evaluation

implementation

interventions

NANDA (North American Nursing Diagnosis Association)

nursing care plans

nursing process

objective data

planning

subjective data

CHAPTER FOCUS

The nursing process is a systematic problem-solving method by which nurses can plan and provide care for clients. This process enables the nurse to identify clients’ actual or potential problems. The nursing process consists of five dynamic and interrelated phases: assessment, diagnosis, planning, implementation and evaluation. This chapter examines the five components of the nursing process and provides nurses with a framework for care planning, which is systematic and methodical.

LIVED EXPERIENCE

I watched my buddy nurse admit a new client today. Mrs Brown is 77 years old and is going to have surgery tomorrow. I observed how the nurse gave Mrs Brown time to settle into the ward and introduce her to the other clients in the room. We all sat down together and started to obtain Mrs Brown’s nursing history. I began to see what the lecturers really meant by the nursing process — this was just the beginning.

Gabrielle, Enrolled Nurse student

Essentially the nursing process is a series of planned steps that produce a particular end result. Specifically, the nursing process is a modified scientific method of systematic problem solving. In simple terms the nursing process is a method used to assess the clients’ needs and plan, deliver and evaluate nursing care. The process of nursing, or scientific method of problem solving, remains the same whether the nursing care provided is a simple measure or a sequence of complicated nursing activities.

AN OVERVIEW OF THE NURSING PROCESS

Providing the framework for nursing care, the nursing process consists of five components, each of which follows logically one after the other:

• Assessment

• Nursing diagnosis

• Planning

• Implementation

• Evaluation.

It is important for the nurse to recognise that the process is ongoing and cyclical in that each step relies on the step preceding and the step following. Figure 19.1 shows diagrammatic representation of the nursing process.

Figure 19.1 Components of the nursing process

To meet clients’ changing needs it is essential to revise and update any plan of care continually. Using the nursing process, each individual’s specific needs are addressed, any problems are identified, and a care plan is developed and implemented to meet those needs. The effectiveness of any care given is continuously evaluated in terms of meeting clients’ needs (Alfaro-LeFevre 2005).

ASSESSMENT

Nursing assessment is the process of obtaining and communicating information (data) about a client, through a variety of methods. The purpose of obtaining information is to identify areas in which nursing intervention is required. Data may be obtained from the client, from others of significance to them, from health team members, and from the client’s past or present medical and nursing records. The data obtained may be either subjective or objective.

Subjective data are the client’s, or other significant person’s, perceptions, ideas and sensations about a health problem. For example, a client may supply information about their sensations of a painful and itching skin, and state that they feel hot. Objective data are the pieces of information observed or measured by the nurse. For example, the nurse may observe the presence of a rash on the client’s body, and may then measure their temperature and observe that it is elevated. Methods of obtaining both subjective and objective data include the nursing history, physical examination and observation, and laboratory and diagnostic tests (Alfaro-LeFevre 2005).

The nursing history

A nursing history is obtained by talking with the client and/or significant other person and is achieved by means of a structured interview. As it is essential that the information is recorded, the nurse uses a form that has been developed by the health care facility. Through the use of interviewing skills, the nursing history elicits information from the client about their current and past health problems, their lifestyle, activities of living and their psychosocial history. A nursing history centres on the client’s description of their physical, psychological and emotional reactions to their illness and on the resultant changes to their lifestyle. A nursing history:

• Is the first stage of problem solving and planning for immediate and long-term client care

• Establishes an information base on which nursing diagnoses and plans for care can be built

• Helps nurses to initiate a positive relationship with the client and enables the nurse to observe the client’s verbal and non-verbal communication

• Provides clients with an opportunity to discuss their feelings about themselves and their health problems

• Helps to reveal any past, present and potential problems that may require nursing intervention

• Helps clients to remember certain aspects of their illness that may have been forgotten or omitted

• Provides a written framework in which to record information about the client’s physical, functional, psychological and emotional state

• Creates a reference point from which the nurse can monitor a client’s progress throughout the illness (Crisp & Taylor 2005).

A nursing history should be obtained as soon as possible after the client’s admission to the health care agency and should be conducted, when feasible, by the nurse with primary responsibility for planning the client’s care. Before beginning the interview the nurse must explain its purpose so the client understands why certain questions will be asked. The interview setting should be quiet and private for the client to feel comfortable about discussing personal details. If a client is too ill or is unable to communicate effectively (perhaps because of language barriers), a nursing history may be obtained by talking with a family member. It is important to record on the nursing assessment form from whom the information is obtained. The nurse may need to reassure the client that the conversation will be confidential (Crisp & Taylor 2005).

It is essential that any information obtained during the interview is documented accurately and concisely, as the nursing assessment form is retained for future reference together with other documentation. The basic information, which should be obtained in a nursing history includes:

• Medical diagnosis

• Previous illnesses and admissions to hospital

• Any medications or known allergies

• The client’s perception of their current state of health

• Social data; for example, type of accommodation and home conditions, interests and recreational activities, next of kin and/or significant others in their life, significant life crises, employment status, religious beliefs and practices, the name by which the client prefers to be called

• Performance of the activities of daily living; for example, degree of independence or any difficulty in maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal hygiene and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping, concerns about dying and grieving

• Use of any prosthesis; for example, walking stick or artificial limb, and any impairments; for example, visual, auditory, or speech

• Habits; for example, use of alcohol, nicotine or non-prescription drugs (Alfaro-LeFevre 2005).

Physical examination and observation

The physical examination is conducted by a medical officer and findings are recorded in the client’s notes. The medical officer uses the techniques of inspection, palpation, percussion and auscultation to detect any abnormalities that may provide information about the client’s health problem. The nurse is able to refer to the medical officer’s documentation for information about the client that is relevant to the planning and implementation of nursing care.

Observation of the client is performed by the nurse during the interview and requires the incorporation of a head-to-toe assessment, which relies on utilising all the senses and good communication skills. Open-ended questions will allow the client to elaborate, to tell their story and to express themself; for example: ‘How would you describe the pain in your arm?’ This type of question also helps the nurse to gather more information. Closed questions elicit a yes or no or more limited response and limit the development of rapport; for example: ‘Do you ever get short of breath?’

The head-to-toe assessment involves assessing factors such as skin colour, general appearance, degree of mobility and independence, emotional status and the presence of obvious abnormalities, such as a rash. Information about the client’s general physical status is obtained by measuring body temperature, pulse, ventilations and blood pressure. The client’s weight (mass) and height are also measured and recorded. This information provides baseline data on which to assess the client’s present health status and may be useful for identifying actual or potential nursing problems (Jarvis 2008).

Cultural considerations in health assessment

Values provide the foundation for beliefs, attitudes and behaviours.

Beliefs include opinions, knowledge and faith about various aspects of the world. How the individual defines illness is based on his or her belief system, for example, Chinese health beliefs in terms of yin (e.g. cold) and yang (e.g. hot). Chinese medicine treatments usually involve restoring balance by applying opposing forces, for example, application of the appropriate ‘hot’ remedy to treat a ‘cold’ illness, and vice versa.

Customs are learned behaviours that the nurse can easily assess through observation and direct questioning. Customs include dietary practices, communication patterns, religious practices and health behaviours.

Heredity is any information concerning ethnic, cultural or racial heritage and is also important for assessing the person’s susceptibility to specific genetic disorders (Jarvis 2008).

Socioeconomic status is important in assessing health. Public health records show that people in lower socioeconomic groups have the highest rates of death and disease resulting from virtually every health problem. For more information on cultural diversity, see Chapter 9.

Laboratory and diagnostic tests

Laboratory and diagnostic tests, which are the most objective form of assessment data, provide another source of information about the client. Both subjective and objective data are required for comprehensive assessment of the client, as they provide more information than either could provide alone. For example, during the nursing interview a client may reveal that she feels tired constantly (subjective data). The nurse observes that she looks extremely pale and the laboratory test results indicate that her haemoglobin level is below normal (objective data). Thus, the laboratory test data provide verification of the alterations from normal (tiredness and pallor) identified during the interview. (See Clinical Interest Box 19.1 for a case study of the assessment phase.)

CLINICAL INTEREST BOX 19.1 Case study — the assessment phase

At the start of the assessment phase for Mrs Brown, 77, admitted to hospital at 1800 hours on 20 June 2009 for surgery the following day, the nurse came to obtain a nursing history. The nurse introduced herself and explained that the purpose of the nursing history was to obtain the information necessary to develop a care plan for her.

The nurse drew the screens around the bed, sat down and began to talk with Mrs Brown. She asked the client by what name she preferred to be known and was informed that ‘Mrs Brown’ would be fine, as she was not enamoured with her given name of Annie. During the 20-minute discussion with Mrs Brown, the nurse obtained and recorded the following information:

• Mrs Brown’s husband had died of cancer 2 years previously. She had one daughter and one son, who both lived some distance away. Her daughter came to stay with her once or twice a month, while her son visited 2–3 times a year. Neither of her children had married

• Mrs Brown lived alone in the house she had shared with her husband since their marriage. The house had all the facilities she required, but was located on a large block so that Mrs Brown was experiencing some difficulty in maintaining the garden without her husband’s assistance. Mrs Brown had one cat, which she enjoyed looking after and said, ‘She is good company’

• Mrs Brown had been an active member of several organisations but had given up some of her social activities over the past 18 months when her eyesight began to fail. She still enjoyed reading, watching television and working in the garden

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