Editing Fundamentals of Nursing (section)

== The nursing process ==

The nursing process is a five step, cyclical problem solving framework. It is the organizing structure for nursing care plans, for clinical documentation, and for the majority of licensure examination items. The steps are assessment, diagnosis (analysis), planning, implementation, and evaluation, commonly memorized as ADPIE.

=== Assessment ===

Assessment is the systematic, deliberate collection of data about the patient. It always comes first. When an examination item offers a plausible intervention and a plausible assessment, choose assessment unless the situation is an emergency with an obvious required action, such as an unwitnessed collapse or an airway obstruction.

* '''Subjective data''' are what the patient reports: pain, nausea, dizziness, fatigue, fear. Pain is always subjective and the patient's self-report is the single most reliable indicator.
* '''Objective data''' are what the nurse observes or measures: vital signs, wound appearance, gait, laboratory values, intake and output.
* '''Primary source''' is the patient. '''Secondary sources''' include family, the medical record, and other members of the health care team.
* '''Types of assessment''' include the comprehensive admission assessment, the focused assessment of a specific problem or body system, the ongoing or shift assessment, and the emergency assessment.

Techniques of physical assessment are inspection, palpation, percussion, and auscultation, performed in that order for every region except the abdomen. For the abdomen, auscultate before palpating, because palpation alters bowel sounds.

Scope note: in the registered nurse role, assessment means the comprehensive evaluation and the clinical interpretation of findings. The licensed practical nurse performs focused data collection, contributes findings to the assessment, and reports changes to the registered nurse. The initial and comprehensive assessment is a registered nurse responsibility and cannot be delegated.

=== Diagnosis and analysis ===

The nursing diagnosis is a clinical judgment about a human response to an actual or potential health problem that nurses are licensed and competent to treat independently. It differs from a medical diagnosis, which names a disease. A patient may carry the medical diagnosis of stroke and the nursing diagnoses of impaired physical mobility, impaired swallowing, and risk for aspiration.

Standard structures include:
* '''Actual problem (three part, PES):''' problem, related to etiology, as evidenced by signs and symptoms. Example: impaired skin integrity related to prolonged pressure over the sacrum as evidenced by a 2 cm stage 2 sacral pressure injury.
* '''Risk problem (two part):''' the risk label plus risk factors. Risk diagnoses have no signs and symptoms yet, because the problem has not occurred. Example: risk for falls as evidenced by unsteady gait, sedating medication, and history of two falls in six months.
* '''Health promotion diagnosis:''' a readiness for enhanced response in a patient who wishes to improve.

The etiology must be something nursing can address. Writing "related to congestive heart failure" is not useful, because a nurse cannot independently treat heart failure. "Related to decreased cardiac output and activity intolerance" points toward nursing action.

=== Planning ===

Planning sets priorities and writes measurable, patient centered outcomes.

Priority setting frameworks:
* '''Airway, breathing, circulation.''' Airway first, always. A patient who cannot maintain an airway outranks a patient who is hemorrhaging, who outranks a patient in pain.
* '''Maslow's hierarchy.''' Physiologic needs before safety, safety before love and belonging, then esteem, then self actualization. Use this when no ABC problem is present.
* '''Acute before chronic, unstable before stable, unexpected before expected.''' New onset confusion in an older adult is a priority. Chronic stable joint pain is not.
* '''Safety and risk of harm.''' A problem that will cause imminent injury outranks one that will not.

Outcome statements should be specific, measurable, attainable, realistic, and time limited. They describe the patient's behavior, not the nurse's action. "The patient will ambulate 50 feet with a walker and standby assistance by postoperative day two" is an outcome. "The nurse will ambulate the patient" is an intervention.

Care plan development, revision, and evaluation are registered nurse responsibilities. Licensed practical nurses contribute to and carry out the plan.

=== Implementation ===

Implementation is the performance of nursing interventions. Interventions are independent (nurse initiated, such as repositioning, teaching, or elevating an extremity), dependent (requiring a provider order, such as administering a medication), or collaborative or interdependent (carried out with other disciplines, such as a physical therapy mobility program).

Before any intervention, verify the patient with two identifiers, perform hand hygiene, explain the procedure, and provide privacy. After any intervention, document what was done, the patient's response, and any follow up needed.

=== Evaluation ===

Evaluation compares the patient's actual response with the expected outcome and determines whether the outcome was met, partially met, or not met. If the outcome is not met, the nurse reassesses, revises the diagnosis or the plan, and continues the cycle. Evaluation is a registered nurse responsibility.