The Nursing Process

1. The Nursing Process Assessment Dr. Belal Hijji, RN, PhD January 24th & 27th 2011

2. Learning Objectives At the end of this lecture, students will be able to: • Describe the phases of the nursing process. • Identify major characteristics of the nursing process. • Identify the nature and purpose of assessment. • Differentiate between subjective and objective data, and primary and secondary sources of data. • Identify three methods of data collection, and give an example of the usefulness of each. • Identify the components of nursing health history.

3. Phases of the Nursing Process • The nursing process has five phases. These are: Assessment, diagnosis, planning, implementation, and evaluation. • The phases are NOT separate entities; they overlap. For example, assessment which is the first phase is carried out during implementation and evaluation. For instance, while doing a cool sponge bath (implementing) for a patient with fever, the nurse can repeatedly measure temperature. On completing the bath, the nurse can re-measure body temperature to evaluate the effectiveness of the intervention. • Each phase of the nursing process affects the others. For example, if the nurse collects inadequate data during assessment and assumes that patient’s noncompliance with medication regimen is due to lack of knowledge, the nursing diagnosis will be incorrect. This will lead to inaccurate planning, implementation, and evaluation.

4. Phases of the Nursing Process • Assessment: An adult patient has fever [39.4C], productive cough, rapid labored respiration [RR 28/m], tachycardia [HR 96/m], and normal blood pressure. The nursing history reveals “chest cold” for one week, shortness of breath upon exertion, high temperature from yesterday, and chest pain. Auscultation reveals crackles (These are due to the movement of air through the alveolar fluid) • Diagnosis: Ineffective airway clearance related to accumulated mucus obstructing airways. • Planning: The nurse and patient establish mutual goals (restore effective breathing pattern); set outcome criteria (have symmetrical chest excursion); and develop a care plan that include, but is not limited to, coughing and deep breathing exercises q3h, fluid intake of 3000 cc daily, and daily postural drainage.

5. Chest excursion refers to chest expandability; it is used to assess symmetrical chest expansion anteriorly and posteriorly. Place your hands vertically on as seen below, with fingers spread and thumbs at the eighth to the tenth rib posteriorly. Your palms should be firm against the skin, with thumbs touching and fingers lightly in contact with the chest wall. Gently gather a small fold of skin between your contacting thumbs. Have the patient take a deep breath. You should feel equal pressure on your hands, and your thumbs should move apart evenly. If you note any abnormality, move your hands up and assess the apices of the lung.

6. A B N O R M A L F I N D I N G S / R AT I O N A L E Asymmetrical excursion: Associated with thoracotomy (removal of lung or lobes), complete or partial airway obstruction, pleural effusion, and pneumothorax. Decreased excursion: May occur in patients with overinflated lungs and fixed diaphragm (COPD). May also be present with splinting because of pain of fractured ribs.

7. Implementation: • Deep breathing exercises q3h at daytime. • Increase fluid intake. • Accommodate postural drainage in morning activities. Postural drainage aims to loosen and mobilize secretions. • Evaluation: Upon assessment of chest excursion, the nurse detects failure to achieve maximum ventilation. This outcome warrants re-evaluation of the care plan and modifying it to increase coughing and deep breathing exercises to q2h.

8. Major Characteristics of the Nursing Process • Data from each phase provide input into the next phase. Findings from evaluation feed back into assessment. • The nursing process is client-centred. The nurse organises the care plan according to patient’s problems. • The nursing process is an adaptation of problem solving. It is parallel to, but separate from, the process used by physicians (medical model). • Decision making is involved in every phase of the nursing process. • The nursing process is interpersonal and collaborative. It requires nurses to communicate with patients/ relatives to meet their needs. Nurses also collaborate with other professionals to provide quality patient care.

9. Nature and Purpose of Assessment • Assessment is the systematic and continuous collection, organisation, validation, and documentation of data (information). • Assessment is carried out during all phases of the nursing process. For example, in evaluation, assessment is carried out to answer the question on achieving the outcomes of nursing interventions and to evaluate goal achievement. • The purpose of assessment is to establish a database about the patient’s response to health concerns or illness and the ability to manage health care needs.

10. Subjective and Objective Data, Primary and Secondary Sources of Data • Subjective data: refer to as symptoms or covert data. They are apparent only to the person affected and can be described or verified by that person. Itching, pain, and feelings of worry are examples of subjective data. • Objective data: refer to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled. Examples include discoloration of the skin or vital signs reading. • The patient is the primary and best source of data. The problem here is that patients could be too ill, young, or confused to communicate clearly. • All sources other than the patient are considered secondary sources of information, and where possible, data from these sources should be validated.Examples of secondary sources include family members, medical records, and healthcare providers.

11. Main Methods of Data Collection and their Usefulness • Observing: This involves gathering data using the senses of vision (weight, skin color), smell (body or breath odors), hearing (heart sounds, bowel sounds), and touch (pulse rate, skin temperature & moisture). An observation has two aspects: (a) noticing the data and (b) selecting, organising, and interpreting the data. For example, face flushing is an observation that the nurse must relate to body temperature, activity, environmental conditions, or blood pressure. • Interviewing: This is a planned communication with a purpose in mind. This could be for giving or getting information, identification of problems of mutual concern, evaluating change, teaching, and/ or providing therapy. An example of an interview is the nursing health history.

12. Examining: Nurses carry out physical examination which is a systematic data collection that uses observation to detect health problems. The techniques that nurses use to conduct physical assessment are inspection, auscultation, palpation, and percussion. These are described next.

13. Inspection • Definition: Using the senses of vision, smell, and hearing to observe the condition of various body parts and recognise any deviations. • Technique: • Expose concerned body parts • Always look before touching • Use good lighting • Perform inspection in warm room • Observe for color, size, location, texture, symmetry, odors, and sound.

14. Auscultation • Definition: Auscultation is listening for various breath, heart, vasculature, and bowel sounds using a stethoscope. • Technique: Use a good stethoscope (Slide 15) that has: • Snug-fitting ear plugs. • Tubing not longer than 15 inches and an internal diameter not greater than 1 inch. • Diaphragm and bell. The diaphragm detects breath sounds, normal heart sounds, and bowel sounds. The bell detects extra heart sounds, heart murmers, and carotid bruits.

16. Palpation • Definition: Palpation is touching and feeling body parts with hands to determine texture, temperature, moisture, motion, and consistency of structures. • Technique: • Nails to be shortened. • Use the part of the hand based on type of sensation to be felt. • Light palpation (< 1 cm) (Slide 17) precedes deep palpation (2.5 – 5 cm) (Slide 18). • Tender areas are palpated last. • Use the type of palpation based on the purpose of the exam. Continued….

19. Percussion (Slide 20) • Definition: Percussion is tapping a portion of the body to elicit tenderness or sounds that vary with the density of underlying structure. • Percussion helps to detect inflamed underlying structures. Percussion in this case can elicit pain. • The reliability of percussion is often questioned due to variations in its specificity and sensitivity.

21. Components of the Nursing Health History • Health perception-health management pattern • Purpose: To determine how the client perceives and maintains his health. • Nutritional-metabolic pattern • Purpose: to determine the client’s dietary habits and metabolic needs. In addition, the conditions of hair, skin, nails, and mucus membranes are assessed. • Elimination pattern • Purpose: to determine the adequacy of function of the client’s bowel and bladder for elimination. • Activity-exercise pattern • Purpose: to determine the client’s activities of daily living, including routines of exercises, leisure, and recreation.

22. Sexuality-reproduction pattern • Purpose: to determine the client’s fulfilment of sexual needs and perceived level of satisfaction. • Sleep-rest pattern • Purpose: to determine the client’s perception of the quality of his sleep, relaxation, and energy level. • Sensory-perceptual pattern • Purpose: to determine the functioning status of the five senses. • Cognitive pattern • Purpose: to determine the client’s ability to understand, communicate, remember, and make decisions.

23. Role-relationship pattern • Purpose: to determine the client’s perceptions of responsibilities and roles in the family, at work, and in social life. • Self- perception – self-concept pattern • Purpose: to determine the client’s perception of his identity, abilities, body image, and self worth. • Coping-stress tolerance pattern • Purpose: to determine the areas and amount of stress in the client’s life and the effectiveness of the coping methods used to deal with it. • Value-belief pattern • Purpose: to determine the client’s values and goals, and beliefs that influence his choices and decisions.