The Nursing Process: Risk For Injury


Nursing is a profession which is prominent across the world. When society changes, nursing also changes. Nurses possess a skill unlike other professionals; nurses must master more information than ever before

available about human health and disease. Not only do nurses have to be intelligent but they also must be good leaders and team members, as well. Nurses must learn to think in a variety of different ways. Critical and creative thinking is often necessary and communication skills must be optimal. A successful nurse must also grapple with practical, ethical, and legal dilemmas. All of the above qualities make what it takes to be a reputable nurse, who can execute the nursing process effectively (Chitty 1).

Nursing is “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA 7). The science of nursing is based on a critical thinking framework, known as the nursing process.

The nursing process is composed of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. These steps serve as the foundation of clinical decision making and are used to provide practice for patients. Nurses are always using critical thinking to respond to the needs of clients, and use strategies that support a promising outcome most appropriate for the patient’s situation (Wilkinson 1-3).

Recently, some nursing leaders have been questioning the effectiveness of the nursing process. These subjects argue that by using the nursing process system, nurses are merely writing a textbook diagnosis rather than successfully looking at the patient’s case. Most agree, however, that the nursing process is important because the nursing process benefits the clients by focusing on them. The nursing process promotes collaboration between the health team by delivering effective, individualized care, and the work atmosphere becomes more positive. The nursing process also prevents errors and speeds up diagnosis, treatment, and prevention of patient problems; this means that the client will spend less time in a hospital and therefore lowers cost. The nursing process also makes it easier to understand what nurses do and individualizes care for the patient that the doctor can not provide in a few simple steps (Wilkinson 7-9)

The first step of the nursing process is the assessment phase: getting the facts. In this first stage, the nurse collects, organizes, validates and records data about the patient’s current health status. The data is collected in a systematic and ongoing process. Data is obtained through examination of the patient, talking to the client and their family, and reading charts and records. While examining the patient, appropriate evidence based assessment techniques and instruments are used. No conclusions are drawn from this first stage (Wilinson 14). The nurse then prioritizes data collection based on the patient’s immediate needs, or anticipated needs of the patient or situation. The registered nurse synthesizes the available data, information and knowledge relevant to the situation to identify patterns and variances. The nurse documents everything in this first stage (ANA 21). Data may possibly include physiological, psychological, socio-cultural, developmental, spiritual, or environmental information. In this initial phase, the patient’s available financial or material resources also need to be assessed and recorded.

Within this first step of the nursing process, there are two separate types of data: subjective data and objective data. Subjective data are gathered from patients as they express their needs, feelings, strengths, and perceptions of the problem. This data can often be referred to as symptoms. The only source for this data is the patient. Subjective data includes physical, psychosocial, and spiritual information. The other type of information is objective data. These are the data that the nurse obtains through observation, examination, or discussion with other health providers (Chitty 394-395).

The patient’s data can be obtained through many sources during the assessment phase of the nursing process. The patient is considered the primary source. Sources of data that the nurse observes or reports of family and friends of the patient are considered secondary sources. Tertiary sources include medical records and information gathered from other health providers (Potter-Perry 279-285).

The second phase of the nursing process is the diagnosis stage. In this stage, the nurse sorts, clusters and analyzes data in order to identify the patient’s current health status. The nurse also writes a description of the patient’s status and the factors that are contributing to it. The nurse prioritizes the nursing diagnoses and finally decides which diagnosis will respond to nursing care and which need another professional (Quan).

NANDA, the North American Nursing Diagnosis Association, provides a standardized set of labels for nurses to use in writing nursing diagnoses. This organization is the leader in nursing diagnoses classification. NANDA-approved nursing diagnoses consist of five components: label, definition, defining characteristics, risk factors, and related factors. The first component, label, is a concise term or phrase used to name the diagnosis. The second part, definition, clearly explains the meaning and helps to set apart from alike diagnoses. The third piece, defining characteristics, contains bunched of observable inferences. The fourth aspect, risk factors, is the factors that increase danger to the patient, which could lead to an unhealthful event. The final factor, related factors, is features that are associated with the diagnosis (Chitty 397)

The third standard of the nursing process is planning outcomes. Planning begins with the identification of the patient’s goals. The goals that are decided upon help the patient and nurse to guide the selection of interventions and to evaluate patient progress. While determining the desired outcome, a period of time for the change to occur is also decided on. The nurse also must consider the patient’s risks, benefits, costs, current evidence, and clinical expertise when formulating expected outcomes. The nurse also documents the expected outcomes as measurable goals (ANA 25).

This third stage is much more complicated than it appears at the surface. Outcome criteria must be decided on, which is what ddefines the terms under which the goal is said to be met, partially met or unmet. Also, there are several types of patient goals. A goal that requires motor skills is a psychomotor goal. A cognitive goal deals with a desired change in a patient’s knowledge level. Affective goals involve a change in mood, values, beliefs or attitudes. All goals are established along with a time period. Short-term goals may be attainable in hours or days; whereas, long-term goals usually represent a major change that could take months or even years (Chitty 400).

The fourth stage, planning interventions, is when the registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. The plan is sensitive to the patient’s characteristics and the situation. The nurse includes strategies within the plan that address each of the identified diagnoses or issues, which may involve strategies for promotion and restoration of health and prevention of illness, injury and disease. The plan incorporates the timeline previously decided on and the nurse establishes the plan’s priorities with the patient, family and others as appropriate. The nurse always must consider the economic impact of the plan on the patient, and when everything is established, the nurse must document the plan in the medical files. The end product of this phase is almost always a written plan of care; however, in some cases, planning is simply the mental process of choosing what to do. Acting without a written plan is acceptable; acting without a plan is not (Wilkinson 15).

The fifth stage of the nursing process is implementation. In this phase, the nurse communicates the plan of care to other members of the healthcare team and carry out the interventions indicated on the plan or delegate them to others. While the nurse is doing this, the nurse is sure to do so in a safe and timely manner. The nurse also documents any modifications, including changes or omissions, of the identified plan. The nurse must also do his/her best to utilize community resources and systems to execute the plan. The final activity of this phase is to record the care given and the client’s responsiveness (ANA 26).

In this phase, interventions vary widely, depending on the nursing diagnosis and the patient goals. As the nurse is carrying out the intervention, he/she is continually assessing the patient, noting responses to interventions and modifying the care plan as needed.

The final stage of the nursing process is the evaluative stage. This phase includes the nurse’s examination of the patient’s progress in relation to the goals and stated outcome criteria to determine whether a problem has been resolved, is in the process of being resolved, or is unresolved. During the evaluation, the nurse conducts a systematic, ongoing, and criterion-based evaluation of the outcomes in relation to the structures and processes prescribed by the plan and the indicated timeline. The evaluation stage may reveal the data, diagnosis, goals, and nursing interventions were all on target and that the problem is resolved, or it may also reveal the need for a new diagnosis and plan (Chitty 403-404).

The nursing process is not so easily separated into steps when it is being practiced in a place of medical care, but all the steps are always used and effective if used properly. The process is often necessary in delivering care to both well and ill clients by identifying the patient’s current health status and focusing on desired outcomes. The nursing process is a developed, reliable and easy-to-work-with system that will continue to last for decades.

Risk For Injury
A visiting nurse is seeing Siegfried Bannat, an 85 year-old man, at his home. The patient has been recovering from a mild stroke affecting his left side. Mr. Bannat lives alone but receives visits from his three sons and granddaughter Kimberly, who live a mere 5 miles away. The visiting nurse’s assessment included a discussion of Mr. Bannat’s health problem and how the stroke has affected him, as well as a pertinent physical examination.
Assessment:
Activities
Ask Mr. Bannat how the stroke has affected his mobility
Conduct a home hazard assessment
Observe Mr. Bannat’s step and posture
Assess Mr. Bannat’s muscle strength
Assess visual acuity with corrective
Findings
Mr. Bannat responds, “I bump into things, and I am afraid I am going to fall.”
Cabinets in the kitchen are in disarray and full of breakable items that could fall out. Throw rugs on floors; bathroom lighting is poor; bathtub lacks safety strips or grab bars; home cluttered with furniture and small objects.
Mr. Bannat has kyphosis and has a hesitant, uncoordinated walk. He frequently holds walls for support.
Left arm and leg are weaker than the right.
Mr. Bannat has trouble reading and seeing familiar objects at a distance while wearing current glasses.
Nursing Diagnosis:
Risk for injury related to impaired mobility, decreased viscal acuity, and physical environmental hazards
Planning:
Goal
Home will be free of hazards within 1 month.
Client and family will be knowledgeable of potential hazards for Mr. Bannat’s age-group within 1 week.
Mr. Bannat will express greater sense of feeling safe from falls in 1 month.
Client will be free of injury in two weeks.
Expected Outcomes
Risk Control: modifiable hazards in kitchen and hallway will be reduced in the home within 1 week. Revisions to bathroom completed in 1 month.
Knowledge of Personal Safety: Client and granddaughter will identify risks and the steps to avoid them in the home at the conclusion of a teaching session next week.
Safety Behavior, Fall Prevention: Mr. Bannat will report improved vision with the aid of new eyeglasses.
Client will be able to safely ambulate throughout the home and perform personal care activities within two weeks
Interventions/Implementations:
Fall Prevention:
A) Review findings from home hazard assessment with client and granddaughter
B) Establish a list of priorities to modify, and have Mr. Bannat’s granddaughter assist in installing bathroom safety devices
C) Install brighter lighting throughout the home. Have granddaughter install blinds over kitchen windows
D) Discuss with client and granddaughter the normal changes of aging, effects of recent stroke, associated risks for injury, and how to reduce risks
E) Encourage daughter to schedule vision testing for new prescription within 2 to 4 weeks
F) Refer to a physical therapist to assess need for assistive devices for kyphosis, left sided weakness, and gait
Rationale:
A) Fall risks for homebound older adults include visual disturbances, unsteady walk, and postural changes. Evaluation of home hazards will highlight extrinsic factors that may lead to falls
B) Modification of environment reduces fall risks
C) With aging, the pupil loses the ability to adjust to light, causing sensitivity to glare. Glare can make it difficult to clearly see a walking path.
D) Education regarding hazards can reduce fear of falling
E) Improved visual acuity reduces incidence of falls
F) Exercise often improves balance and flexibility. Modifying walking problems by increasing lower extremity strength reduces fall risk.
Evaluation:
Nursing Actions:
1. Ask client and family to identify risks
2. Observe environment for elimination of hazards
3. Reassess Mr. Bannat’s visual acuity
4. Observe Mr. Bannat’s gait and posture
Client Response/Finding:
1. Mr. Bannat and granddaughter able to identify risks during a walk through the home and expressed a greater sense of safety as a result of changes made
2. Throw rugs have been removed ad lighting has been increased to 75 watts except in bathroom and bedroom
3. Mr. Bannat has new glasses and says he can read better, as well as see distance objects more clearly
4. Mr. Bannat’s walking gait is still hesitant and uncoordinated; he reports that his granddaughter has not had time to take him to physical therapy
Achievement of Outcome
1. Client and granddaughter are more knowledgeable of potential hazards
2. Environmental hazards have been partially reduced
3. Mr. Bannat’s vision has improved, enabling him to move more safely
4. Outcome of safe ambulation has not solely been achieved; continue to encourage Mr. Bannat and granddaughter to go to physical therapy apoointments.

References
American Nurses Association. (2004). Nursing Scope and Standards or Practice (5th ed.). Silver Spring, Maryland: American Nurses Association.
American Psychological Association. (2002). Publication Manual of the American Psychological Association (5th ed.). Washington, DC: American Psychological Association.
Chitty, K. K. (2005). Professional Nursing Concepts and Challenges (4th ed.). St. Louis, Missouri: Elsevier Saunders.
Potter, P. A., & Perry, A. G. (2005). Fundamentals of Nursing (6th ed.). St. Louis, Missouri: Mosby.
Quan, K. (2007). The Nursing Process. About: Nursing.
Wilkinson, J. M. (2007). Nursing Process and Critical Thinking (4th ed.). Upper Saddle River, NJ: Pearson Education.

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