Nursing process: Clinical decision making

The nursing process is an iterative framework used by nurses to identify actual and potential patient issues, create and implement plans of care, and evaluate responses to care.

Following the steps of the nursing process is integral for exercising clinical judgment and making informed clinical decisions.

The nursing process allows nurses to successfully navigate patient needs within various clinical scenarios and is essential for providing safe, quality care and improving patient outcomes.

So there are several versions of the nursing process, each represented by an acronym representing the steps. Perhaps the most well-known version is ADP, which is a five-step process that includes assessment, diagnosis, planning, implementation, and evaluation.

There's also a 6th step process, Ay, which adds an O for outcome identification. Lastly, a shorter version is API, where the diagnosis step is integrated with an assessment instead of standing on its own.

OK, let's take a closer look at each version. Starting with ADP, A stands for assessment, which refers to the objective and subjective information the nurse gathers about a patient.

Subjective data includes verbal statements from the patient or the primary caregiver regarding their current condition, past medical history, and medications, whereas objective data refers to measurable information like vital signs and laboratory results.

Next, D is for diagnosis, where the nurse analyzes the previously collected assessment data to identify and define the patient's most pressing health problems and needs, which are often called nursing diagnoses.

These diagnoses will guide the steps taken to address problems during step P or planning. During planning, the nurse formulates patient-centered goals and develops interventions that will address the diagnosed problem and guide the plan of care.

The plan of care is then carried out during step I or implementation where the nurse and healthcare team members execute the interventions aimed at meeting the identified goals.

Lastly, E is for evaluation, which involves assessing the effectiveness of the interventions and modifying the care plan as needed.

For instance, if the nurse notices that the patient's condition hasn't improved or if new issues are discovered during reassessment, the nursing process starts over from the beginning.

Moving on to Adopi, this process includes an additional step called outcome identification between diagnosis and planning.

While outcome identification, also called goal setting, is typically part of the planning stage in ADP, Adopi offers this as a separate step dedicated to establishing clear outcomes before planning interventions.

These outcomes or goals should be specific, measurable, achievable, relevant, and time-bound, or smart for short, to ensure that planning is structured and patient-centered.

Finally, in AI, the diagnosis step is integrated into the assessment phase. Although the diagnosis isn't singled out, the nurse must still organize and analyze the collected data to identify the most pressing patient issues to guide interventions.

The relevance of traditional nursing diagnosis language in clinical practice is a topic of debate. However, the process of identifying and describing patient problems continues to play a valuable role in supporting clinical judgment and guiding clinical decision making.

Now, let's look at a scenario where a nurse uses the API version of the nursing process to make decisions and prioritize care.

Nurse Nick is caring for an adult patient named Libby who recently underwent an open reduction and internal fixation to repair a right tibial fracture and is now recovering in the orthopedic unit.

Nurse Nick enters Libby's room to perform his shift assessment. He measures Libby's vital signs, which are temperature 98.5 °F or 36.9 °C, heart rate 102 BPM, respirations 18 breaths per minute.

BP 152/91 millimeters of mercury. Oxygen saturation 98% on room air, and a pain at a 7 out of 10 described as burning at the incision site.

Nurse Nick also sees that her body posture is tense, and she holds her breath during movement. He then inspects Libby's lower right extremity and notes that the fracture site is splinted.

He gently looks under the splint and sees that while Libby's transparent dressing is dry and intact, there's localized bruising and edema around the area.

He then performs a neurovascular assessment distal from the incision site, which reveals a capillary refill of less than 3 seconds, a strong pedal pulse, and intact movement.

She also denies experiencing any numbness to the affected extremity. Examination on the left side reveals an extremity that appears pink.

Non-edematous and nontender capillary refill is also less than 3 seconds with a strong pedal pulse. Then nurse Nick reviews the EHR and notes that Libby's BP normally runs between 110 and 120 millimeters of mercury systolic and 60 to 70 millimeters mercury diastolic, and her heart rate is usually between 60 and 80 BPM.

He also sees that up until recently her pain has been rated tolerable at a 3 out of 10 or below. Additionally, nurse Nick notices that Libby is ordered to have a postoperative venous thromboembolism or VTE prophylaxis with the administration of low molecular weight heparin, and application of sequential compression devices.

Based on his findings, Nurse Nick analyzes the information. He determines that Libby is experiencing severe pain from her surgical incision, and her BP and heart rate are higher than usual, likely due to pain.

He knows that without proper pain management, Libby's recovery and healing can be delayed. He also understands that due to immobility, anesthesia, and the trauma from surgery, Libby is at risk of developing a postoperative deep vein thrombosis or DVT, which could potentially travel to her lungs as a VTE.

Without proper prevention measures, her risk of VTE significantly increases. Based on this analysis, Nurse Nick begins planning Libby's care.

He prioritizes care to address her main problems, starting with preventing a potential VTE, treating her pain, and stabilizing her vital signs.

He establishes the following goals during the shift. Libby won't develop a VTE.

Her pain level will be managed at her stated tolerable level of 3 out of 10 or less, and her BP and heart rate will return to her baseline.

Next, nurse Nick implements the plan of care. He begins by explaining the interventions to Libby, who is in agreement.

He then administers the prescribed heparin and pain medication following the principles of safe medication administration.

He also elevates Libby's lower right leg using pillow support to promote comfort and applies a prescribed ice pack near the incision.

Next, he attaches one sequential compression device onto Libby's left lower leg and an adapted one to her right foot to avoid putting pressure on the incision.

Understanding that early mobilization can also prevent VTE, Nurse Nick ensures that a physical therapy referral is in place for later that day.

One hour later, nurse Nick evaluates the outcomes of his interventions. He measures Libby's vital signs, which are temperature 98.7 °F or 37.1 °C, heart rate 88 BPM, respirations 16 breaths per minute, BP 130/77 millimeters of mercury, and oxygen saturation 98% on room air.

She appears more comfortable and rates her pain as 2 out of 10. Nurse Nick performs another neurovascular assessment and notes no changes from baseline.

He does not see any signs of DVT formation such as calf swelling, pain, or warmth. Since Libby's pain is under control, her vital signs have stabilized, and she isn't showing any sign of blood clot formation.

Nurse Nick determines his plan of care was successful. He'll continue to use API throughout his shift to help guide clinical judgment and make decisions regarding Libby's care.

All right, as a quick recap, the nursing process is an iterative framework used by nurses to identify actual and potential patient issues, create and implement plans of care, and evaluate responses.

There are several nursing process models including AP, Adipi. And Apii By integrating the nursing process into clinical decision making, nurses can promote quality patient care and improve health outcomes.