CHAPTER 4

The Nursing Process

EDVERLY T. MALANA, MSN, RN
 • Specific to the nursing profession

• -A framework for critical thinking

What is • - It’s purpose is to:“Diagnose and treat human

responses to actual or potential health problems”

• - Organized framework to guide practice

Nursing • - Problem solving method - client focused

• - Systematic- sequential steps

Process • - Goal oriented- outcome criteria

• - Dynamic-always changing, flexible

? • - Involves looking at the whole patient at all times

- It provides a "road map" that ensures good
nursing care & improves patient outcomes
 • - Provides individualized care

• -Client is an active participant

Advantages • -Promotes continuity of care

• -Provides more effective communication
among nurses and healthcare
professionals
of Nursing • -Develops a clear and efficient plan of
care
• -Provides personal satisfaction as you see
Process: client achieve goals
• - Professional growth as you evaluate
effectiveness of your interventions
5 STEPS IN
THE
NURSING
PROCESS
 • -First step of the Nursing Process
• - systematic, deliberate process by
which the nurse collects and analyzes
data about the patient
• -Gather Information/Collect Data through
Nursing Interview (history), Health
ASSESSMENT Assessment -Review of Systems, Physical
Exam
• -Entire plan is based on the data you
collect, data needs to be complete and
accurate
• - Make sure information is complete &
accurate
5 Activities Needed to Perform a Systematic Assessment

Collect Verify Organiz

data data e data
Report
Identify &
Patterns Record
data
Comprehensive data collection:

- Begins before you actually see the patient (Nurse report from ER, Chart reviews)

-Continues with admission interview and physical assessment once you meet patient.

-Other information resources include: family, significant others, nursing records, old medical
records, diagnostic studies, relevant nursing literature.

-Consider age, growth & development

 Sources of data:

b. Secondary
Source -
physical exam,
a. Primary
nursing history,
Source - Client /
team members,
Family
lab reports,
diagnostic
 a. Subjective -from the client (symptom) “I have a
headache”

Types
b. Objective - observable data (sign) Blood Pressure
130/80

• Example:

of ∙ Obtain info from nursing assessment, history and

physical (H&P) etc…...

data:
∙ Client diagnosed with hypertension

∙ BP 160/90mmhg

∙ 2 Gm Na diet and antihypertensive medications

were prescribed

∙ Client statement “ I really don’t watch my salt” “

It’s hard to do and I just don’t get it
VITAL SIGNS-
indicators of health status, these measures indicate the effectiveness of circulatory, respiratory, neural
and endocrine body functions.

- it provides data to determine a client’s usual state of heath (baseline data).

- -it is a quick and efficient way of monitoring a client’s condition or identifying problems evaluating
the client’s response to intervention.
Guidelines for Measuring Vital Signs:

• a. Body Temperature - Reflects the balance between the heat produced and the heat lost from
the body

• -Measured in heat units called degrees

Two kinds:

∙ Core temperature - The temperature of the deep tissues of the body and remains relatively
constant.

∙ Surface temperature - Is the temperature of the skin, in the subcutaneous tissue, and fat.

• - Rises and falls in response to environment.

Factors Affecting the Body’s Heat Production

∙ Basal Metabolic Rate (BMR)

-The rate of energy utilization in the body required to maintain essential activities such as
breathing.

-Metabolic rates increase with age.

-In general, the younger the person, the higher the BMR.

∙ Thyroxine Output

-Increased thyroxine output increases the rate of cellular metabolism throughout the body.

-Epinephrine, norepinephrine and sympathetic stimulation

-These hormones immediately increase the rate of cellular metabolism in many body tissues.

-Epinephrine and norepinephrine directly affect the liver and muscle cells, thereby increasing
cellular metabolism.
Factors affecting Heat Loss:

∙ Radiation

• -Is the transfer of heat from the surface of one object to the surface without contact between the two objects.

• -Example: nude person standing in a room of a normal room temperature.

∙ Conduction

• -Is the transfer from one molecule to a molecule of lower temperature.

• -Conductive transfer cannot take place without contact between the molecules.

∙ Convection

• - Dispersion of heat by air currents.

∙ Vaporization

• - Is the continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from
the skin.
Common Types of Fever:

∙ Intermittent

• - Body temperature alternates at a regular intervals between periods of fever and periods of normal or subnormal
temperatures.

∙ Remittent

• - Wide range of temperature fluctuations (more than 2 C) over a period of 24 hours, all of which are above normal

∙ Relapsing

• - Short febrile periods of a few days are interspersed with periods of 1-2 days of normal temperature.

∙ Constant

• - Fluctuates minimally but always remains above normal.

∙ Fever spike

• - A temperature that rises to fever level rapidly following a normal temperature and then returns to normal within a few
hours.
 SITE ADVANTAGE DISADVANTAGES
S
ORAL Accessible -Thermometers can break if bitten.
and -Inaccurate if client has just ingested hot or cold
convenient food or fluid or smoked.
-Could injure mouth following oral surgery.
Assessing RECTAL Reliable -Inconvenient and more unpleasant for clients.
-Difficult for clients who cannot turn to the side.

Body -Could injure the rectum following rectal

temperature.

Temperature:
- Presence of stool may interfere with the
thermometer placement.

AXILLARY Safe and non- -The thermometer must be left in place a long
invasive time to obtain an accurate measurement.
TYMPANIC Readily -Can be uncomfortable and involves risk of
MEMBRAN accessible; injuring the membrane if the probe is inserted too
E reflects the far.
core -Repeated measurements may vary.
temperature, - Presence of cerumen may affect the reading.
very fast

TEMPORA Safe and -Requires electronic thermometers that may be

L ARTERY noninvasive; inexpensive or unavailable.
very fast
b. Pulse

• -Wave of blood created by contraction of the left ventricle of the heart.

• -Peripheral pulse-a pulse located away from the heart.

• -Apical pulse-central pulse, located at the apex of the heart, also called PMI
 PULSE SITE REASONS FOR USING SPECIFIC PULSE SITE
Radial -Readily accessible

PULSE
Temporal -Used when radial pulse is not accessible
Carotid -Used during cardiac arrest/shock in adults
-Used to determine circulation to the brain

SITES: Apical -Routinely used for infants and children up to 3 years of age.
-Used to determine discrepancies with radial pulse.
-Used in conjunction with some medications.
Brachial -Used to measure blood pressure
-Used during cardiac arrest for infants
Femoral -Used in cases of cardiac arrest/shock
-Used to determine circulation to the leg
Popliteal -Used to determine circulation to the lower leg
Posterior tibial -Used to determine circulation to the foot
Dorsal Pedal -Used to determine circulation to the foot
Assessing the Pulse:

∙ Commonly assessed by palpation or auscultation.

∙ Use the middle three fingertips for all pulse sites except
for the apex of the heart.

∙ Use moderate pressure.

∙ A doppler ultrasound stethoscope is used for pulses that

are difficult to assess.

∙ The pads on the most distal aspects of the finger are

most sensitive areas for detecting pulse.
∙ The nurse should be aware of the
following:
o Any medication that could affect
the heart rate.
o Whether the client has been
physically active. If so, wait 10-15
minutes until the client has rested
and the pulse has slowed to its
usual rate.
o Any baseline data about the
normal heart rate for the client.
o Whether the client should assume
a particular position.
c. Respirations

∙ Act of breathing

∙ Inhalation or inspiration: intake of air into

the lungs.

∙ Exhalation or expiration: refers to the

breathing out or the movement of gases
from the lungs to the atmosphere.

∙ Ventilation: is also used to refer to the

movement of air in and out of the lungs.
Two types of breathing:

∙ Costal (thoracic) breathing- involves the external intercostal muscles

and other accessory muscles, such as sternocleidomastoid muscles.
• -Can be observed by the movement of the chest upward and
outward.
∙ Diaphragmatic breathing - Involves the contraction and relaxation of
the abdomen.
• - Observed by the movement of the abdomen, which occurs as
a result of the diphragm’s contraction and downward movement
 ∙ Resting respirations should be assessed when
the client is relaxed because exercise affects
respirations.

∙ Before assessing, a nurse should be aware of;

o patient’s normal breathing pattern
Assessing o influence of the client’s health problems on
Respirations: respirations

∙ Any medications or therapies that might affect

respirations

∙ The relationship of the client’s respirations to

cardiovascular function
 RATE
What should be assessed?
Eupnea Normal rate &
depth
Bradypnea Abnormally
∙ Rate
slow
∙ Depth
Polypnea/ Abnormally fast
∙ Rhythm Tachypnea
respirations
∙ Quality
Apnea Cessation of
∙ Special characteristics of
respirations breathing
• Depth:

∙ Deep – are those in which a large volume of air is inhaled & exhaled, inflating most of the lungs

∙ Shallow – involve the exchange of a small volume of air and often the minimal use of lung tissue

• Rhythm:

∙ Cheyne-stokes breathing- Rhythmic waxing and waning of respirations from very deep to very
shallow breathing and temporary apnea.

• Ease of Effort:

∙ Dyspnea- difficult and labored breathing

∙ Orthopnea-ability to breathe only in upright sitting or standing positions.

BREATH SOUNDS:

∙ Stridor – a shrill, harsh sound heard during inspiration with laryngeal obstruction

∙ Stertor – snoring or sonorous respiration, usually due to a partial obstruction of the upper airway

∙ Wheeze – continous, high-pitched musical squeak or whistling sound occuring on expiration and
sometimes on inspiration when air moves through a narrowed or partially obstructed airway

∙ Bubbling- gurgling sounds heard as air passes through moist secretions in the respiratory tract

∙ Crackles – dry or wet crackling sounds simulated by rolling a lock of hair near the ear

∙ Gurgles – coarse, dry, wheezy or whistling sound more audible during expiration as the air moves
through tenacious mucus or narrowed bronchi
CHEST MOVEMENTS:

∙ Intercostal retractions-indrawing between the ribs

∙ Substernal retractions-indrawing beneath the breast bone

∙ Suprasternal retraction-indrawing above the clavicles

d. Blood Pressure

∙ A measure of the pressure exerted by the blood moves in waves

∙ SYSTOLIC PRESSURE – the pressure of the blood as a result of contraction of the ventricles

∙ DIASTOLIC PRESSURE – the pressure when the ventricles are at rest

∙ PULSE PRESSURE-difference between SBP and DBP- Normal=40 mmHg

 CATEGORY SBP DBP
Classification Normal <120 <80
of Blood Prehypertension 120-139 80-89
Pressure:
Hypertension, 140-159 90-99
Stage 1
Hypertension, >160 >100
Stage 2
e. Pain
• The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory
and emotional experience, which we primarily associate with tissue damage or describe in terms of
such damage, or both.
Classifications of Pain:

∙ Acute pain-usually associated with an injury with recent onset and duration of less than six
months and usually less than a month.

∙ Chronic Pain- usually associated with a specific cause or injury and is described as a constant

∙ Cancer Pain- often due to the compression of peripheral nerves or meninges or from the damage
to the structures following surgery, chemotherapy, radiation, or tumor growth and infiltration
∙ Phantom Limb Pain – it is a pain perceived by a residual body part.
Health Assessment for Pain

• Collecting Subjective Data

❖ Pain is a subjective phenomenon and thus the main assessment lies in the client’s reporting. The
client’s description of pain is quoted. The exact words used to describe the experience of pain are
used to help in the diagnosis and management.
History of Present Illness

❖ Use the COLDSPA mnemonic as a guideline to collect information. In addition the following questions help elicit important
information .

• Character: Describe the pain in your own words. How does it feel, look sound, smell and so forth?

• Clients are quoted so that terms used to describe their pain may indicate the type and source. The most common terms
used are: throbbing, shooting, stabbing sharp, cramping, gnawing, hot-burning, aching, heavy, tender, splitting, tiring-
exhausting, sickening, fearful, punishing.

• Onset: When did the pain begin?

• The onset of pain is an essential indicator for the severity of the situation and suggests a source.

• Location: Where is the pain located? Does it radiate or spread? The location of the pain helps to identify the underlying
cause.

• Duration: How long does the pain lasts? Does it recur?Is the pain continuous or intermittent?

• Understanding the course of the pain provides a pattern that may help to determine the source.
• Severity: How bad is it?

• To determine the degree of perceived pain.

• Pattern: What factors relieve your pain? What factors increase your pain?

• Identifying factors that relieve or increase pain helps to determine the source and the plan of
care.

• Associated factors: Are there any concurrent symptoms accompanying the pain?

• Accompanying symptoms also help to identify the possible source. For example, right lower
quadrant pain associated with nausea, vomiting and the inability to stand up straight is possibly
associated with appendicitis.
Past Health History

❖ Have you had any previous experience with pain?

• Past experiences of pain may shed light on the previous history of the client in addition to
possible positive or negative expectations of pain therapies.
Family History

❖ Does any in your family experience pain?

• To assess possible family-related perception or any past experiences with person in pain.

❖ How does pain affect your family?

• To assess how much the pain is interfering with the client’s family relations.
Lifestyle and Health Practices

❖ What are your concerns about pain?

• Identifying the client’s fears and worries helps in prioritizing the plan of care and
providing adequate psychological support.
❖ How does your pain interfere with the following?
• -General Activity
• -Mood/Emotions
• -Concentration
• -Physical Ability
• -Work
• -Relations with other people
• -Sleep
• -Appetite
• -Enjoyment of life
Methods of Assessment
• Interview
• Physical Assessment
• Inspection
• Percussion
• Palpation
• Auscultation
NURSING DIAGNOSIS

• - Second step of the Nursing Process

• - provide a basis for selection of nursing interventions so that goals and outcomes can be achieved

• -Interpret & analyze clustered data

• -Identify client’s problems and strengths

• -Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis Association)-Statement of how
the client is RESPONDING to an actual or potential problem that requires nursing intervention

• - responsible for recognizing health problems, anticipating complications, initiating actions to ensure
appropriate and timely treatment.

• - Apply critical thinking to problem identification

• -Requires knowledge, skill, and experience

NURSING DIAGNOSIS MEDICAL DIAGNOSIS
Within the scope of nursing Within the scope of medical
practice practice

Identify responses to health Focuses on curing pathology

and illness

Can change from day to day Stays the same as long as the
disease is present
• Formulating a Nursing Diagnosis

∙ Use accepted qualifying terms (Altered, Decreased, Increased, Impaired)

∙ Don’t use Medical Diagnosis (Altered Nutritional Status related to Cancer)

∙ Don’t state 2 separate problems in one diagnosis

∙ Refer to NANDA list in a nursing text book ( North American Nursing Diagnosis Association it
formally identifies, develops, and classifies nursing diagnoses)
Composed of 3 parts:

∙ Problem statement ( Diagnostic Label)-based on your assessment of clienT(gathered information),

• - pick a problem from the NANDA list

• - the client’s response to a problem

∙ Etiology- what’s causing/contributing to the client’s problem

• - determine what the problem is caused by or related to (R/T)

∙ Defining Characteristics- what’s the evidence of the problem

• -then state as evidenced by (AEB) the specific facts the problem is based on…

• EXAMPLE:

• Ineffective therapeutic regimen management related to difficulty maintaining lifestyle changes and lack
of knowledge as evidenced by B/P= 160/90, dietary sodium restrictions not being observed, and client
statements of “ I don’t watch my salt” “It’s hard to do and I just don’t get it”.
TYPES OF NURSING DIAGNOSIS

∙ Actual- Patient problem & Causes if known

- Imbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and pain AEB
height 5’5” weight 105 lbs.

∙ Risk - Problem & Risk Factors

• - patient is at risk for developing this problem

-Example: Risk for falls RT altered gait and generalized weakness

∙ Wellness- (NANDA) describes human responses to levels of wellness in an individual, family, or

community that have a readiness for enhancement
-Example: Family coping: potential for growth RT unexpected birth of twins.
. PLANNING

• - Third step of the Nursing Process

• - This is when the nurse organizes a nursing care plan based on the nursing diagnoses.

• - Nurse and client formulate goals to help the client with their problems

• -Expected outcomes are identified

• -Interventions (nursing orders) are selected to aid the client reach these goals.

• - Begin by prioritizing client problems

• -Prioritize list of client’s nursing diagnoses using Maslow

• -Set your priorities of care, what needs to be done first, what can wait.
• -Apply Nursing Standards, Nurse Practice Act, National practice
guidelines, hospital policy and procedure manuals.
• -Identify your goals & outcomes, derive them from nursing
diagnosis/problem.
• -Determine interventions, based on goals.
• -Record the plan (care plan/concept map)
• -Client specific Priorities can change
• Types of Goals:

∙ Short term- goal can be achieved in a reasonable amount of time ( few hours to few days)

∙ Long term- goals may take weeks/months to be achieved

∙ Cognitive goals

∙ Psychomotor goals

∙ Affective goals

• - Goals are patient-centered and SMART (Specific Measurable Attainable Relevant Time Bound)
IMPLEMENTATION- The fourth step in
the Nursing Process

• - This is the “Doing” step

• - Interventions will be collaborative, combining nursing actions and physician orders.

• - Carrying out nursing interventions (orders) selected during the planning step

• -This includes monitoring, teaching, further assessing, reviewing NCP, incorporating physicians
orders and monitoring cost effectiveness of interventions

• INTERVENTION - are treatments or actions based on clinical judgment and knowledge that
nurses perform to enhance patient outcomes.
• 3 TYPES OF INTERVENTION

∙ Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision

∙ Dependent ( Physician initiated )-nursing actions requiring MD orders

∙ Collaborative- nursing actions performed jointly with other health care team members
EVALUATION - To determine effectiveness of NCP

• -Final step of the Nursing Process but also done concurrently throughout client care

• -A comparison of client behavior and/or response to the established outcome criteria

• - Step of the nursing process that measures the client’s response to nursing actions and the
client’s progress toward achieving goals

• -Data collected on an on-going basis

• -Supports the basis of the usefulness and effectiveness of nursing practice

• -Involves measurement of Quality of Care

• - Evaluation of individual plan of care includes determining outcome achievement

• -Identify variables/factors affecting outcome achievement

• -Decide where to continue/modify/terminate plan

• -Continue/modify/terminate plan based on whether outcome has been met (partially or

completely)