On completing this chapter, you will be able to do the following: 1. Discuss how the nursing process has evolved from the 1950s to the present. 2. Define your role in the nursing process according to the Nurse Practice Act in your state, territory, or country. 3. Describe assisting with the four steps of the nursing process for the practical/vocational nurse: a. Data collection (assessment) 4. Describe nursing diagnosis as the exclusive domain of the registered nurse (RN). 5. Explain why the nursing process and critical thinking are part of the practical/vocational nursing program curriculum. 6. Briefly describe how NANDA-I, NIC, and NOC can be used together to plan patient care. Definitions of the nursing process for the NCLEX-PN® examination (NCSBN, 2001) are as follows: • Data collection (assessment) is a systematic gathering and review of information about the patient, which is communicated to appropriate members of the health team. • Planning involves assisting the RN in the development of nursing diagnosis, goals, and interventions for a patient’s plan of care and maintaining patient safety. • Implementation is the provision of required nursing care to accomplish established patient goals. • Evaluation compares the actual outcomes of nursing care to the expected outcomes, which are then communicated to members of the health care team. • The definitions of the nursing process remain the same for the 20011 NCLEX-PN® examination. Data collection includes many aspects. • Subjective information is based on the patient’s opinion. Some refer to subjective information as symptoms. This usually includes feelings of physical discomfort, anxiety, and mental stress that are more difficult to measure. The nurse cannot experience subjective symptoms. • Objective information includes data that the nurse can verify; it is also known as “signs.” A physical assessment provides objective data. The terms check, observe, monitor, weigh, measure, and smell are cues that you may be involved in objective data collection. Obtaining initial data, such as vital signs, height, and weight, is often assigned to the LPN/LVN. Objective information helps support or cast doubt on subjective information. For example, a patient’s subjective statement about feeling feverish can be verified by measuring his or her temperature (objective). • Verify the data and question any information that is not a match to your data collection. • Differentiate between subjective and objective data. Remember that decisions must be based on evidence, not assumptions. • Compare findings with the RN and other staff involved with the patient. • Other staff may help verify when a client has mental limitations. • Patients or family members may be able to validate information you obtained during data collection (family members with patient permission). • Document all data and sources, especially when they do not match. • Compare the data you collected with the medical records. • Know that what you do for verification will depend on your skill level and whether you are an SPN/SVN or LPN/LVN. • As a student, ask your instructor for guidance on how to verify data and how to determine if there is a relationship between presenting problems. • Emergency data are reported immediately. For example, suppose you learn that the patient with a fracture has diabetes and fell on his way home from a bar, where he goes daily for “just four beers.” If he says, “I pace myself,” does that reassure you that this is not an immediate issue? Recall that what you have heard is subjective data, but as a student you will not be in a position to verify it further without direction from the RN. Report what you have heard and any objective data, such as vital signs and observations, to the appropriate person. You have just activated your brain to think critically. • Incomplete toolbox: Subjective data will be charted as “Patient states …” Objective data such as temperature, pulse, and respiration (TPR); blood pressure (BP); weight; and skin color will be charted as what you observe and measure without judging or drawing conclusions. Your involvement in this step depends on your place of employment and your experience and skill level. The LPN/LVN usually has more responsibility in the nursing home, where the patient’s condition is more stable. At the conclusion of your practical/vocational program, you will have acquired strong, although incomplete, data collection skills: “The toolbox is not complete.” An incomplete toolbox is nothing to be ashamed of. For example, you measure the TPR and BP properly. Be proud of your data collection skills. They provide valuable data. Data collection starts during the patient’s admission. It continues daily at the beginning of the shift for the baseline observations, then periodically during the shift, and right before doing your final documentation and reporting off. The practical/vocational nurse is always collecting data on therapeutic responses to treatments, interventions, and medications (Box 9-1). • The patient’s first impression of you tends to remain. Address the patient as Mr., Mrs., Miss, Ms., or another title, as appropriate. Avoid using a first name unless you have the patient’s permission. • Remind yourself that this is a professional, not a personal, relationship that you are building. The most common complaints by patients include “I don’t know which one is the nurse”; “I am treated with disrespect”; “I am not their grandma”; and so on. Familiarity—that is, acting toward a patient as though he or she is a family member or friend—does not give the patient a sense of confidence in your nursing skill. • When in the patient’s presence, stand or sit where he or she can see you. Patients often experience fear on being hospitalized or transferred to a new facility. • Confusion or lack of skills on the nurse’s part serves to increase that fear. The focus of the nurse’s job is to serve the patient with the greatest skill possible.
The Nursing Process
Your Role
http://evolve.elsevier.com/Hill/success
The nursing process: 2000 and beyond
Steps of the nursing process
Step 1: data collection
Systematic Way of Gathering Data
Verify the Information
Communicate Information to Appropriate Health Care Team Members
Other Aspects of Data Collection
Data Collection Continues
Introduce Yourself
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The Nursing Process: Your Role
