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Clinical Nursing Skills

1.3 Nursing Process

Clinical Nursing Skills1.3 Nursing Process

Learning Objectives

By the end of this section, you will be able to:

  • Identify the five phases and steps within each phase of the nursing process
  • Develop a nursing care plan using diagnoses from evidence-based sources

The nursing process is a dynamic strategy that allows nurses to find pertinent information and use critical thinking to guide patient care. This allows the nurse to receive a quick handoff report from another nurse, and immediately begin providing care to a newly assigned patient. The nursing process becomes a road map for the actions and interventions that nurses implement to optimize their patients’ well-being and health. This section will explain how to use the nursing process as standards of professional nursing practice to provide safe, patient-centered care.

Phases and Steps of the Nursing Process

The nursing process is a critical thinking model based on a systematic approach to patient-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of Professional Nursing Practice established by the ANA. These standards are authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently. The mnemonic ADPIE is an easy way to remember the ANA Standards and the nursing process. The five components of the nursing process are: assessment, diagnosis, planning, implementation, and evaluation (Figure 1.11).

Diagram showing ADPIE nursing process: Assessment, Diagnosis, Planning, Implementation, Evaluation.
Figure 1.11 The nursing process is a critical thinking model based on a systematic approach to patient-centered care. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Assessment

The assessment phase involves gathering data about the patient’s health status, including physical, psychological, social, and cultural aspects (ANA, 2021). It includes collecting subjective information through interviews and objective data through physical examinations, laboratory tests, and medical records review. This phase sets the foundation for identifying health needs, problems, and strengths.

These assessments can take two primary forms: focused and comprehensive. A focused assessment is conducted with a specific purpose in mind, aiming to gather information about a particular health issue or symptom. They are highly targeted and designed to address a specific concern. For instance, if a patient reports chest pain, a nurse would conduct a focused assessment of the cardiovascular system to determine the cause of the discomfort. Focused assessments are instrumental in identifying and addressing immediate health problems.

On the other hand, a comprehensive assessment provides a more extensive and detailed overview of a patient’s overall health. They encompass physical, psychological, and social aspects of a patient’s well-being. These assessments are often performed to establish a baseline of their health status. Comprehensive assessments may be performed upon admission and repeated periodically during a patient’s hospital stay, especially in cases of complex conditions, to ensure a holistic understanding of the patient’s evolving health needs.

The choice between focused and comprehensive assessments depends on the clinical context and the information required to provide the most effective and appropriate care for the patient. While focused assessments pinpoint specific issues, comprehensive assessments offer a more comprehensive perspective, helping healthcare providers develop comprehensive care plans and monitor overall patient wellness.

Collect Data

This step involves gathering information about the patient’s health status through various methods, including interviews, observations, and physical examinations (American Nurses Association (ANA), 2021). Nurses collect both subjective data (information provided by the patient) and objective data (measurable and observable information). They ask relevant questions, such as any current or past medical issues, and current medications that the patient may be taking. They actively listen to the patient’s concerns using such strategies as maintaining appropriate eye contact, using open body language, asking clarifying questions, and empathizing. This exchange encourages trust between the nurse and patient and encourages the patient to share information. The nurse also uses their observation skills to identify important cues (Figure 1.12) during the patient’s physical assessment and note any abnormal findings.

Man with his head bent and his hands with fingers bent inward placed on his head in apparent distress.
Figure 1.12 A nurse can start an assessment by looking at a patient’s appearance and demeanor. (credit: Untitled by U.S. Department of Defense, Public Domain)

Cultural Context

Cultural Considerations during Assessments

In order for nurses to deliver high-quality care to all patients, it is important they understand that cultural factors can influence a patient’s behaviors, health beliefs, and reaction to medical issues (Agency for Healthcare Research and Quality, 2020). To build effective relationships with culturally diverse patients nurses should:

  • Learn how to interact with diverse patients.
    • Keep an open mind, ask patients about their beliefs, attend cultural competence training, and collaborate with social workers or other cultural experts.
  • Provide appropriate learning materials.
  • Provide qualified medical translators.
  • Strive to build trust.
    • Encourage questions, involve extended family in decision-making, show respect, and utilize culturally inclusive printed materials.

Validate Data

Validation is the process of ensuring the accuracy and reliability of the collected data (ANA, 2021). Nurses compare and cross-reference the information obtained from multiple sources, such as the patient, family members, healthcare team, and medical records. By validating the data, nurses can identify any inconsistencies or discrepancies that may require further clarification or investigation.

Organize Data

Once the data are collected and validated, nurses organize them in a systematic and structured manner. They categorize the information based on body systems, prioritize data based on the patient’s immediate needs, and identify significant findings (ANA, 2021). Organizing the data helps nurses to identify patterns, make connections, and recognize potential health problems or risks.

Document Data

Documentation is a crucial step in the assessment process. Nurses record the collected and organized data in a clear, concise, and accurate manner (ANA, 2021). This documentation serves as a legal and communication tool, ensuring that the information is accessible to the healthcare team and providing a comprehensive picture of the patient’s health status. Accurate documentation supports continuity of care and enables effective collaboration among healthcare providers.

Diagnose/Analyze Data

In the diagnosis phase, nurses analyze and interpret the collected data to identify nursing diagnoses or health problems (ANA, 2021). A nursing diagnosis is a clinical judgment based on the medical diagnosis of a patient that help the nurse determine the plan of care. This step helps in identifying specific nursing interventions and developing an individualized plan of care.

Identify Potential Patient Concerns

In this step, nurses review the gathered data and identify potential health problems or concerns. They critically analyze the information, considering both subjective and objective data, to recognize patterns, deviations from normalcy, and potential risk factors. By applying their clinical knowledge and expertise, nurses develop a list of potential nursing diagnoses that could explain the patient’s health issues.

Identify Actual Patient Concerns

In this step, nurses further refine the list of potential nursing diagnoses and identify the actual health problems or concerns that are present in the patient. They critically evaluate the data, considering the patient’s specific symptoms, responses, and needs. By prioritizing the identified concerns based on their urgency and significance, nurses establish the actual nursing diagnoses that accurately reflect the patient’s current health status.

Apply Data to Clinical Decision-Making

In this final step of the nursing diagnosis phase, nurses utilize the identified nursing diagnoses to guide their clinical decision-making process (ANA, 2021). They use the data gathered during the assessment phase, along with their clinical expertise and EBP, to develop an individualized plan of care. Nurses determine appropriate nursing interventions, establish goals and outcomes, and select strategies to address the identified patient concerns. This step serves as a bridge to the subsequent phases of the nursing process, facilitating the planning, implementation, and evaluation of nursing care.

Planning

In the planning phase, nurses collaborate with the patient, their family, and the interdisciplinary healthcare team to set achievable goals or outcomes and develop a comprehensive plan of care (ANA, 2021). The plan outlines specific interventions, strategies, and expected outcomes to address the identified nursing diagnosis. It takes into account the patient’s preferences, resources, and cultural considerations.

Patient Conversations

Planning Care with a Diverse Patient Population

Scenario: The nurse walks into the room of a patient who has just received a breast cancer diagnosis. The patient, Ash, is 36 years old and nonbinary. The purpose of the visit is to collaborate with Ash to develop a plan of care that suits their needs and wants. Ash has a history of distrust of the healthcare system because of bad past experiences, and the nurse helps reassure them that their needs and wishes are at the center of the plan of care.

Nurse: Good morning, Ash. I’m glad you’re here today. I understand that you’ve recently been diagnosed with breast cancer. We’re here to discuss your care plan, and I want you to know that your input is extremely valuable. How are you feeling about everything?

Patient: Thanks, Nurse. It’s been a rollercoaster of emotions, to be honest. I appreciate your willingness to help, but I’ve had some bad experiences with health care in the past. I’m worried that people won’t listen to me, and that my opinion won’t be taken into account, and it’s causing me a lot of anxiety.

Nurse: I’m really sorry to hear that, Ash. I understand where your concerns are coming from. Your comfort and preferences are absolutely our priority, and I’m here to make sure your care plan respects your wishes. Could you tell me more about the past experiences that worry you?

Patient: Thanks for understanding. Well, in the past, I’ve felt like I didn’t have a say in my treatment, and it left me feeling uncomfortable and unheard. It was like other people were making decisions they thought were best for me without having any idea who I really am and what I want. I just want to be a part of the decision-making process and not feel pressured into something I might regret.

Nurse: I appreciate your honesty, Ash. Your voice matters, and in this care plan, you’ll have a say in every decision. We’ll discuss all your treatment options, goals, and outcomes in detail and you’ll be fully involved in the process. No pressure, just informed choices.

Patient: That’s a relief to hear. I also have some specific preferences regarding my care. I’d really like a gender-neutral and affirming environment, and it’s crucial for me to maintain my privacy and dignity throughout this journey.

Nurse: Your preferences are incredibly important, Ash. We’re committed to providing a welcoming and affirming atmosphere. Privacy and dignity are non-negotiable, and we’ll work together to ensure you feel comfortable at all times. Your gender identity will be respected, and your needs will be met.

Patient: Thank you, Nurse. I’m feeling more at ease already.

Nurse: You’re very welcome, Ash. Your well-being is our top priority, and we’re here to make this journey as smooth as possible. Feel free to ask questions, share your concerns, or just chat anytime.

Patient: I really appreciate that.

Nurse: That’s what we’re here for, Ash. We’re a team, and your needs will guide our care plan. Don’t hesitate to reach out for anything you need along the way. Your comfort and well-being matter deeply to us.

Establish and Prioritize Patient Outcomes

In this step, nurses work collaboratively with the patient, their family, and the healthcare team to establish desired outcomes or goals that reflect the expected changes or improvements in the patient’s health. These outcomes should be specific, measurable, attainable, relevant, and timely (SMART) (Figure 1.13). Consider a nurse who is working with a patient who has just had a heart attack, providing education to them on making healthy dietary choices. An effective SMART goal for this patient may be “I will only eat out at a restaurant once a week.” An ineffective SMART goal for this patient would be “I will only eat out at a restaurant once in a while.” Nurses prioritize the outcomes based on the patient’s needs, values, and preferences, as well as the urgency and significance of the identified concerns.

Diagram showing SMART goals: S: Specific, Who, What, Where, When, Why, Which, Define the goal as much as possible with no ambiguous language, WHO is involved, WHAT do I want to accomplish, WHERE will it be done, WHY am I doing this (reasons, purpose), WHICH constraints / requirements do I have?; M: Measurable, From and To, Can you track the progress and measure the outcome? How much, how many, how will I know when my goal is accomplished?; A: Attainable: How, Is the goal reasonable enough to be accomplished? How so? Make sure the goal is not out of reach or below standard performance; R: Relevant, Worthwhile, Is the goal worthwhile and will it meet your needs? Is each goal consistent with other goals you have established and fits with your immediate and long-term plans?; T: Timely, When, Your objective should include a time limit. “I will complete this step by month/day/year.” It will establish a sense of urgency and prompt you to have better time management.
Figure 1.13 For best outcomes, patient goals should be SMART. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Develop Nursing Interventions

After establishing and planning for patient outcomes, nurses develop nursing interventions or actions that will help the patient achieve those outcomes. These interventions are evidence based and aligned with the nursing diagnosis, incorporating the best available research and clinical guidelines. Nursing interventions can be independent, dependent, or collaborative.

Any intervention that the nurse can independently provide without obtaining a prescription is considered an independent nursing intervention. An example of an independent nursing intervention is when the nurses monitor the patient’s twenty-four-hour intake and output record for trends because of a risk for imbalanced fluid volume. Another example of independent nursing interventions is the therapeutic communication that a nurse uses to assist patients to cope with a new medical diagnosis.

On the other hand, a dependent nursing intervention requires a prescription before it can be performed. Prescriptions are orders, interventions, remedies, or treatments ordered or directed by an authorized primary healthcare provider. For example, administering medication is a dependent nursing intervention. The nurse incorporates dependent interventions into the patient’s overall care plan by associating each intervention with the appropriate nursing diagnosis.

A collaborative nursing intervention is an action that the nurse carries out in collaboration with other health team members, such as physicians, social workers, respiratory therapists, physical therapists, and occupational therapists. These actions are developed in consultation with other healthcare professionals and incorporate their professional viewpoint. An example of a collaborative nursing intervention is consulting with a respiratory therapist when the patient has deteriorating oxygen saturation levels.

Nurses consider the patient’s unique circumstances, resources, and cultural background when formulating the interventions. The interventions may include a direct care activity such as administering medications, providing treatments, and assisting with activities of daily living. They may also involve an indirect care activity such as patient education, counseling, and coordination of healthcare services.

Life-Stage Context

Outcome and Planning for Diverse Populations

When planning nursing interventions for a patient, it is important to consider the patient’s individual circumstances. Two different patients with the same medical diagnosis may have vastly different ideas about what care they consider appropriate based on previous functionality, cultural background, age, and more.

For example, an otherwise healthy 42-year-old female who is diagnosed with a high-risk brain tumor may choose to aggressively pursue all avenues of treatment, including chemotherapy or surgery as needed. On the other hand, an 83-year-old male with a history of type 2 diabetes, kidney failure, coronary bypass surgery, and bilateral below the knee amputations may decide against any kind of aggressive treatment, choosing palliative care or hospice as their plan of care.

In these two examples, the ages and physical functionality of the patients help them to determine what plan of care is right for them. Even though they carry the same medical diagnosis, these two patients will have very different plans of care, including nursing diagnoses, outcomes, and interventions. For these reasons, the nurse must always consider the patient’s unique circumstances and their wishes when developing the plan of care.

Creating a Nursing Care Plan

Nursing care plans are created by registered nurses. Documentation of individualized nursing care plans is legally required in long-term care facilities by the Centers for Medicare and Medicaid Services (CMS) and in hospitals by The Joint Commission (TJC). TJC is an independent, nonprofit organization that is one of the most prominent accrediting bodies for healthcare organizations and facilities in the country. It sets rigorous standards for patient care and safety, quality improvement, and the overall performance of healthcare organizations.

TJC conceptualizes the care planning process as the structuring framework for coordinating communication that will result in safe and effective care (The Joint Commission, n.d.). Many facilities have established standardized nursing care plans (Figure 1.14) with lists of possible interventions that can be customized for each specific patient. Other facilities require the nurse to develop each care plan independently. Whatever the format, nursing care plans should be individualized to meet the specific and unique needs of each patient.

Standardized nursing care plan.
Figure 1.14 A standardized care plan that is customizable may be used in some facilities. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Implementation

The implementation phase involves executing the planned nursing interventions according to the established plan of care (ANA, 2021). Nurses provide direct care, administer medications, deliver treatments, and educate patients and their families. They also coordinate with other healthcare professionals to ensure continuity and quality of care. Documentation of the interventions and patient responses is an essential part of this phase.

Perform Nursing Skills Identified in Planning

In this step, nurses perform the specific nursing skills or interventions identified in the planning phase. These interventions can include administering medications, providing wound care, assisting with mobility, conducting patient education, promoting self-care, and addressing psychosocial needs. Nurses implement the interventions with professionalism, empathy, and adherence to EBP.

Evaluation

The evaluation phase focuses on determining the effectiveness of the nursing interventions and the progress made toward achieving the established goals (ANA, 2021). Nurses assess the patient’s response to interventions, reevaluate the data, and compare the outcomes with the expected results. If needed, modifications to the plan of care are made to promote better patient outcomes and address any new or evolving health needs.

Reassess to Determine if Outcomes Are Achieved

In this step, the nurse conducts a thorough reassessment of the patient to determine the extent to which the established outcomes have been achieved. They assess whether the patient’s health has improved, stabilized, or deteriorated based on the identified criteria. They compare the patient’s current status with the expected outcomes defined in the planning phase. This reassessment involves collecting new data, evaluating changes in the patient’s condition, and reviewing any documentation or feedback from the patient. By evaluating the progress made toward achieving the outcomes, nurses can determine if the interventions have been effective in addressing the identified concerns.

Revise or Terminate Nursing Plan of Care

Based on the evaluation findings, nurses determine whether revisions to the nursing plan of care are necessary or if the plan can be terminated. If the outcomes have been achieved, the plan may be concluded, and the nurse focuses on discharge planning or transition to ongoing care. However, if the outcomes have not been met, the nurse revises the plan by identifying new interventions or modifying existing ones to better support the patient’s progress toward achieving the desired outcomes. Nurses continue to reassess and evaluate the patient’s condition at regular intervals, making adjustments to the plan of care as needed to optimize outcomes and address any emerging concerns.

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